Bill Amendment: IL SB3365 | 2025-2026 | 104th General Assembly

NOTE: For additional amemendments please see the Bill Drafting List

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Bill Title: MEDICARE/MEDICAID DUAL ELIGIBL

Status: 2026-06-16 - Public Act . . . . . . . . . 104-0470 [SB3365 Detail]

Download: Illinois-2025-SB3365-House_Amendment_001.html

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Rep. Anna Moeller

Filed: 5/31/2026

 

 

 

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AMENDMENT TO SENATE BILL 3365
AMENDMENT NO. ______. Amend Senate Bill 3365 by replacing
everything after the enacting clause with the following:
"ARTICLE 2.
Section 2-5. The Illinois Public Aid Code is amended by
changing Section 5-5 as follows:
(305 ILCS 5/5-5)
Sec. 5-5. Medical services. The Illinois Department, by
rule, shall determine the quantity and quality of and the rate
of reimbursement for the medical assistance for which payment
will be authorized, and the medical services to be provided,
which may include all or part of the following: (1) inpatient
hospital services; (2) outpatient hospital services; (3) other
laboratory and X-ray services; (4) skilled nursing home
services; (5) physicians' services whether furnished in the

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office, the patient's home, a hospital, a skilled nursing
home, or elsewhere; (6) medical care, or any other type of
remedial care furnished by licensed practitioners; (7) home
health care services; (8) private duty nursing service; (9)
clinic services; (10) dental services, including prevention
and treatment of periodontal disease and dental caries disease
for pregnant individuals, provided by an individual licensed
to practice dentistry or dental surgery; for purposes of this
item (10), "dental services" means diagnostic, preventive, or
corrective procedures provided by or under the supervision of
a dentist in the practice of his or her profession; (11)
physical therapy and related services; (12) prescribed drugs,
dentures, and prosthetic devices; and eyeglasses prescribed by
a physician skilled in the diseases of the eye, or by an
optometrist, whichever the person may select; (13) other
diagnostic, screening, preventive, and rehabilitative
services, including to ensure that the individual's need for
intervention or treatment of mental disorders or substance use
disorders or co-occurring mental health and substance use
disorders is determined using a uniform screening, assessment,
and evaluation process inclusive of criteria, for children and
adults; for purposes of this item (13), a uniform screening,
assessment, and evaluation process refers to a process that
includes an appropriate evaluation and, as warranted, a
referral; "uniform" does not mean the use of a singular
instrument, tool, or process that all must utilize; (14)

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transportation and such other expenses as may be necessary;
(15) medical treatment of sexual assault survivors, as defined
in Section 1a of the Sexual Assault Survivors Emergency
Treatment Act, for injuries sustained as a result of the
sexual assault, including examinations and laboratory tests to
discover evidence which may be used in criminal proceedings
arising from the sexual assault; (16) the diagnosis and
treatment of sickle cell disease anemia; (16.5) services
performed by a chiropractic physician licensed under the
Medical Practice Act of 1987 and acting within the scope of his
or her license, including, but not limited to, chiropractic
manipulative treatment; and (17) any other medical care, and
any other type of remedial care recognized under the laws of
this State. The term "any other type of remedial care" shall
include nursing care and nursing home service for persons who
rely on treatment by spiritual means alone through prayer for
healing.
Notwithstanding any other provision of this Section, a
comprehensive tobacco use cessation program that includes
purchasing prescription drugs or prescription medical devices
approved by the Food and Drug Administration shall be covered
under the medical assistance program under this Article for
persons who are otherwise eligible for assistance under this
Article.
Notwithstanding any other provision of this Code,
reproductive health care that is otherwise legal in Illinois

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shall be covered under the medical assistance program for
persons who are otherwise eligible for medical assistance
under this Article.
Notwithstanding any other provision of this Section, all
tobacco cessation medications approved by the United States
Food and Drug Administration and all individual and group
tobacco cessation counseling services and telephone-based
counseling services and tobacco cessation medications provided
through the Illinois Tobacco Quitline shall be covered under
the medical assistance program for persons who are otherwise
eligible for assistance under this Article. The Department
shall comply with all federal requirements necessary to obtain
federal financial participation, as specified in 42 CFR
433.15(b)(7), for telephone-based counseling services provided
through the Illinois Tobacco Quitline, including, but not
limited to: (i) entering into a memorandum of understanding or
interagency agreement with the Department of Public Health, as
administrator of the Illinois Tobacco Quitline; and (ii)
developing a cost allocation plan for Medicaid-allowable
Illinois Tobacco Quitline services in accordance with 45 CFR
95.507. The Department shall submit the memorandum of
understanding or interagency agreement, the cost allocation
plan, and all other necessary documentation to the Centers for
Medicare and Medicaid Services for review and approval.
Coverage under this paragraph shall be contingent upon federal
approval.

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Notwithstanding any other provision of this Code, the
Illinois Department may not require, as a condition of payment
for any laboratory test authorized under this Article, that a
physician's handwritten signature appear on the laboratory
test order form. The Illinois Department may, however, impose
other appropriate requirements regarding laboratory test order
documentation.
Upon receipt of federal approval of an amendment to the
Illinois Title XIX State Plan for this purpose, the Department
shall authorize the Chicago Public Schools (CPS) to procure a
vendor or vendors to manufacture eyeglasses for individuals
enrolled in a school within the CPS system. CPS shall ensure
that its vendor or vendors are enrolled as providers in the
medical assistance program and in any capitated Medicaid
managed care entity (MCE) serving individuals enrolled in a
school within the CPS system. Under any contract procured
under this provision, the vendor or vendors must serve only
individuals enrolled in a school within the CPS system. Claims
for services provided by CPS's vendor or vendors to recipients
of benefits in the medical assistance program under this Code,
the Children's Health Insurance Program, or the Covering ALL
KIDS Health Insurance Program shall be submitted to the
Department or the MCE in which the individual is enrolled for
payment and shall be reimbursed at the Department's or the
MCE's established rates or rate methodologies for eyeglasses.
On and after July 1, 2012, the Department of Healthcare

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and Family Services may provide the following services to
persons eligible for assistance under this Article who are
participating in education, training or employment programs
operated by the Department of Human Services as successor to
the Department of Public Aid:
(1) dental services provided by or under the
supervision of a dentist; and
(2) eyeglasses prescribed by a physician skilled in
the diseases of the eye, or by an optometrist, whichever
the person may select.
On and after July 1, 2018, the Department of Healthcare
and Family Services shall provide dental services to any adult
who is otherwise eligible for assistance under the medical
assistance program. As used in this paragraph, "dental
services" means diagnostic, preventative, restorative, or
corrective procedures, including procedures and services for
the prevention and treatment of periodontal disease and dental
caries disease, provided by an individual who is licensed to
practice dentistry or dental surgery or who is under the
supervision of a dentist in the practice of his or her
profession.
On and after July 1, 2018, targeted dental services, as
set forth in Exhibit D of the Consent Decree entered by the
United States District Court for the Northern District of
Illinois, Eastern Division, in the matter of Memisovski v.
Maram, Case No. 92 C 1982, that are provided to adults under

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the medical assistance program shall be established at no less
than the rates set forth in the "New Rate" column in Exhibit D
of the Consent Decree for targeted dental services that are
provided to persons under the age of 18 under the medical
assistance program.
Subject to federal approval, on and after January 1, 2025,
the rates paid for sedation evaluation and the provision of
deep sedation and intravenous sedation for the purpose of
dental services shall be increased by 33% above the rates in
effect on December 31, 2024. The rates paid for nitrous oxide
sedation shall not be impacted by this paragraph and shall
remain the same as the rates in effect on December 31, 2024.
Notwithstanding any other provision of this Code and
subject to federal approval, the Department may adopt rules to
allow a dentist who is volunteering his or her service at no
cost to render dental services through an enrolled
not-for-profit health clinic without the dentist personally
enrolling as a participating provider in the medical
assistance program. A not-for-profit health clinic shall
include a public health clinic or Federally Qualified Health
Center or other enrolled provider, as determined by the
Department, through which dental services covered under this
Section are performed. The Department shall establish a
process for payment of claims for reimbursement for covered
dental services rendered under this provision.
Subject to appropriation and to federal approval, the

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Department shall file administrative rules updating the
Handicapping Labio-Lingual Deviation orthodontic scoring tool
by January 1, 2025, or as soon as practicable.
On and after January 1, 2022, the Department of Healthcare
and Family Services shall administer and regulate a
school-based dental program that allows for the out-of-office
delivery of preventative dental services in a school setting
to children under 19 years of age. The Department shall
establish, by rule, guidelines for participation by providers
and set requirements for follow-up referral care based on the
requirements established in the Dental Office Reference Manual
published by the Department that establishes the requirements
for dentists participating in the All Kids Dental School
Program. Every effort shall be made by the Department when
developing the program requirements to consider the different
geographic differences of both urban and rural areas of the
State for initial treatment and necessary follow-up care. No
provider shall be charged a fee by any unit of local government
to participate in the school-based dental program administered
by the Department. Nothing in this paragraph shall be
construed to limit or preempt a home rule unit's or school
district's authority to establish, change, or administer a
school-based dental program in addition to, or independent of,
the school-based dental program administered by the
Department.
The Illinois Department, by rule, may distinguish and

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classify the medical services to be provided only in
accordance with the classes of persons designated in Section
5-2.
The Department of Healthcare and Family Services must
provide coverage and reimbursement for amino acid-based
elemental formulas, regardless of delivery method, for the
diagnosis and treatment of (i) eosinophilic disorders and (ii)
short bowel syndrome when the prescribing physician has issued
a written order stating that the amino acid-based elemental
formula is medically necessary.
The Illinois Department shall authorize the provision of,
and shall authorize payment for, screening by low-dose
mammography for the presence of occult breast cancer for
individuals 35 years of age or older who are eligible for
medical assistance under this Article, as follows:
(A) A baseline mammogram for individuals 35 to 39
years of age.
(B) An annual mammogram for individuals 40 years of
age or older.
(C) A mammogram at the age and intervals considered
medically necessary by the individual's health care
provider for individuals under 40 years of age and having
a family history of breast cancer, prior personal history
of breast cancer, positive genetic testing, or other risk
factors.
(D) A comprehensive ultrasound screening and MRI of an

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entire breast or breasts if a mammogram demonstrates
heterogeneous or dense breast tissue or when medically
necessary as determined by a physician licensed to
practice medicine in all of its branches.
(E) A screening MRI when medically necessary, as
determined by a physician licensed to practice medicine in
all of its branches.
(F) A diagnostic mammogram when medically necessary,
as determined by a physician licensed to practice medicine
in all its branches, advanced practice registered nurse,
or physician assistant.
(G) Molecular breast imaging (MBI) and MRI of an
entire breast or breasts if a mammogram demonstrates
heterogeneous or dense breast tissue or when medically
necessary as determined by a physician licensed to
practice medicine in all of its branches, advanced
practice registered nurse, or physician assistant.
The Department shall not impose a deductible, coinsurance,
copayment, or any other cost-sharing requirement on the
coverage provided under this paragraph; except that this
sentence does not apply to coverage of diagnostic mammograms
to the extent such coverage would disqualify a high-deductible
health plan from eligibility for a health savings account
pursuant to Section 223 of the Internal Revenue Code (26
U.S.C. 223).
All screenings shall include a physical breast exam,

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instruction on self-examination and information regarding the
frequency of self-examination and its value as a preventative
tool.
For purposes of this Section:
"Diagnostic mammogram" means a mammogram obtained using
diagnostic mammography.
"Diagnostic mammography" means a method of screening that
is designed to evaluate an abnormality in a breast, including
an abnormality seen or suspected on a screening mammogram or a
subjective or objective abnormality otherwise detected in the
breast.
"Low-dose mammography" means the x-ray examination of the
breast using equipment dedicated specifically for mammography,
including the x-ray tube, filter, compression device, and
image receptor, with an average radiation exposure delivery of
less than one rad per breast for 2 views of an average size
breast. The term also includes digital mammography and
includes breast tomosynthesis.
"Breast tomosynthesis" means a radiologic procedure that
involves the acquisition of projection images over the
stationary breast to produce cross-sectional digital
three-dimensional images of the breast.
If, at any time, the Secretary of the United States
Department of Health and Human Services, or its successor
agency, promulgates rules or regulations to be published in
the Federal Register or publishes a comment in the Federal

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Register or issues an opinion, guidance, or other action that
would require the State, pursuant to any provision of the
Patient Protection and Affordable Care Act (Public Law
111-148), including, but not limited to, 42 U.S.C.
18031(d)(3)(B) or any successor provision, to defray the cost
of any coverage for breast tomosynthesis outlined in this
paragraph, then the requirement that an insurer cover breast
tomosynthesis is inoperative other than any such coverage
authorized under Section 1902 of the Social Security Act, 42
U.S.C. 1396a, and the State shall not assume any obligation
for the cost of coverage for breast tomosynthesis set forth in
this paragraph.
On and after January 1, 2016, the Department shall ensure
that all networks of care for adult clients of the Department
include access to at least one breast imaging Center of
Imaging Excellence as certified by the American College of
Radiology.
On and after January 1, 2012, providers participating in a
quality improvement program approved by the Department shall
be reimbursed for screening and diagnostic mammography at the
same rate as the Medicare program's rates, including the
increased reimbursement for digital mammography and, after
January 1, 2023 (the effective date of Public Act 102-1018),
breast tomosynthesis.
The Department shall convene an expert panel including
representatives of hospitals, free-standing mammography

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facilities, and doctors, including radiologists, to establish
quality standards for mammography.
On and after January 1, 2017, providers participating in a
breast cancer treatment quality improvement program approved
by the Department shall be reimbursed for breast cancer
treatment at a rate that is no lower than 95% of the Medicare
program's rates for the data elements included in the breast
cancer treatment quality program.
The Department shall convene an expert panel, including
representatives of hospitals, free-standing breast cancer
treatment centers, breast cancer quality organizations, and
doctors, including radiologists that are trained in all forms
of FDA-approved breast imaging technologies, breast surgeons,
reconstructive breast surgeons, oncologists, and primary care
providers to establish quality standards for breast cancer
treatment.
Subject to federal approval, the Department shall
establish a rate methodology for mammography at federally
qualified health centers and other encounter-rate clinics.
These clinics or centers may also collaborate with other
hospital-based mammography facilities. By January 1, 2016, the
Department shall report to the General Assembly on the status
of the provision set forth in this paragraph.
The Department shall establish a methodology to remind
individuals who are age-appropriate for screening mammography,
but who have not received a mammogram within the previous 18

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months, of the importance and benefit of screening
mammography. The Department shall work with experts in breast
cancer outreach and patient navigation to optimize these
reminders and shall establish a methodology for evaluating
their effectiveness and modifying the methodology based on the
evaluation.
The Department shall establish a performance goal for
primary care providers with respect to their female patients
over age 40 receiving an annual mammogram. This performance
goal shall be used to provide additional reimbursement in the
form of a quality performance bonus to primary care providers
who meet that goal.
The Department shall devise a means of case-managing or
patient navigation for beneficiaries diagnosed with breast
cancer. This program shall initially operate as a pilot
program in areas of the State with the highest incidence of
mortality related to breast cancer. At least one pilot program
site shall be in the metropolitan Chicago area and at least one
site shall be outside the metropolitan Chicago area. On or
after July 1, 2016, the pilot program shall be expanded to
include one site in western Illinois, one site in southern
Illinois, one site in central Illinois, and 4 sites within
metropolitan Chicago. An evaluation of the pilot program shall
be carried out measuring health outcomes and cost of care for
those served by the pilot program compared to similarly
situated patients who are not served by the pilot program.

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The Department shall require all networks of care to
develop a means either internally or by contract with experts
in navigation and community outreach to navigate cancer
patients to comprehensive care in a timely fashion. The
Department shall require all networks of care to include
access for patients diagnosed with cancer to at least one
academic commission on cancer-accredited cancer program as an
in-network covered benefit.
The Department shall provide coverage and reimbursement
for a human papillomavirus (HPV) vaccine that is approved for
marketing by the federal Food and Drug Administration for all
persons between the ages of 9 and 45. Subject to federal
approval, the Department shall provide coverage and
reimbursement for a human papillomavirus (HPV) vaccine for
persons of the age of 46 and above who have been diagnosed with
cervical dysplasia with a high risk of recurrence or
progression. The Department shall disallow any
preauthorization requirements for the administration of the
human papillomavirus (HPV) vaccine.
On or after July 1, 2022, individuals who are otherwise
eligible for medical assistance under this Article shall
receive coverage for perinatal depression screenings for the
12-month period beginning on the last day of their pregnancy.
Medical assistance coverage under this paragraph shall be
conditioned on the use of a screening instrument approved by
the Department.

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Any medical or health care provider shall immediately
recommend, to any pregnant individual who is being provided
prenatal services and is suspected of having a substance use
disorder as defined in the Substance Use Disorder Act,
referral to a local substance use disorder treatment program
licensed by the Department of Human Services or to a licensed
hospital which provides substance abuse treatment services.
The Department of Healthcare and Family Services shall assure
coverage for the cost of treatment of the drug abuse or
addiction for pregnant recipients in accordance with the
Illinois Medicaid Program in conjunction with the Department
of Human Services.
All medical providers providing medical assistance to
pregnant individuals under this Code shall receive information
from the Department on the availability of services under any
program providing case management services for addicted
individuals, including information on appropriate referrals
for other social services that may be needed by addicted
individuals in addition to treatment for addiction.
The Illinois Department, in cooperation with the
Departments of Human Services (as successor to the Department
of Alcoholism and Substance Abuse) and Public Health, through
a public awareness campaign, may provide information
concerning treatment for alcoholism and drug abuse and
addiction, prenatal health care, and other pertinent programs
directed at reducing the number of drug-affected infants born

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to recipients of medical assistance.
Neither the Department of Healthcare and Family Services
nor the Department of Human Services shall sanction the
recipient solely on the basis of the recipient's substance
abuse.
The Illinois Department shall establish such regulations
governing the dispensing of health services under this Article
as it shall deem appropriate. The Department should seek the
advice of formal professional advisory committees appointed by
the Director of the Illinois Department for the purpose of
providing regular advice on policy and administrative matters,
information dissemination and educational activities for
medical and health care providers, and consistency in
procedures to the Illinois Department.
The Illinois Department may develop and contract with
Partnerships of medical providers to arrange medical services
for persons eligible under Section 5-2 of this Code.
Implementation of this Section may be by demonstration
projects in certain geographic areas. The Partnership shall be
represented by a sponsor organization. The Department, by
rule, shall develop qualifications for sponsors of
Partnerships. Nothing in this Section shall be construed to
require that the sponsor organization be a medical
organization.
The sponsor must negotiate formal written contracts with
medical providers for physician services, inpatient and

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outpatient hospital care, home health services, treatment for
alcoholism and substance abuse, and other services determined
necessary by the Illinois Department by rule for delivery by
Partnerships. Physician services must include prenatal and
obstetrical care. The Illinois Department shall reimburse
medical services delivered by Partnership providers to clients
in target areas according to provisions of this Article and
the Illinois Health Finance Reform Act, except that:
(1) Physicians participating in a Partnership and
providing certain services, which shall be determined by
the Illinois Department, to persons in areas covered by
the Partnership may receive an additional surcharge for
such services.
(2) The Department may elect to consider and negotiate
financial incentives to encourage the development of
Partnerships and the efficient delivery of medical care.
(3) Persons receiving medical services through
Partnerships may receive medical and case management
services above the level usually offered through the
medical assistance program.
Medical providers shall be required to meet certain
qualifications to participate in Partnerships to ensure the
delivery of high quality medical services. These
qualifications shall be determined by rule of the Illinois
Department and may be higher than qualifications for
participation in the medical assistance program. Partnership

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sponsors may prescribe reasonable additional qualifications
for participation by medical providers, only with the prior
written approval of the Illinois Department.
Nothing in this Section shall limit the free choice of
practitioners, hospitals, and other providers of medical
services by clients. In order to ensure patient freedom of
choice, the Illinois Department shall immediately promulgate
all rules and take all other necessary actions so that
provided services may be accessed from therapeutically
certified optometrists to the full extent of the Illinois
Optometric Practice Act of 1987 without discriminating between
service providers.
The Department shall apply for a waiver from the United
States Health Care Financing Administration to allow for the
implementation of Partnerships under this Section.
The Illinois Department shall require health care
providers to maintain records that document the medical care
and services provided to recipients of Medical Assistance
under this Article. Such records must be retained for a period
of not less than 6 years from the date of service or as
provided by applicable State law, whichever period is longer,
except that if an audit is initiated within the required
retention period then the records must be retained until the
audit is completed and every exception is resolved. The
Illinois Department shall require health care providers to
make available, when authorized by the patient, in writing,

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the medical records in a timely fashion to other health care
providers who are treating or serving persons eligible for
Medical Assistance under this Article. All dispensers of
medical services shall be required to maintain and retain
business and professional records sufficient to fully and
accurately document the nature, scope, details and receipt of
the health care provided to persons eligible for medical
assistance under this Code, in accordance with regulations
promulgated by the Illinois Department. The rules and
regulations shall require that proof of the receipt of
prescription drugs, dentures, prosthetic devices and
eyeglasses by eligible persons under this Section accompany
each claim for reimbursement submitted by the dispenser of
such medical services. No such claims for reimbursement shall
be approved for payment by the Illinois Department without
such proof of receipt, unless the Illinois Department shall
have put into effect and shall be operating a system of
post-payment audit and review which shall, on a sampling
basis, be deemed adequate by the Illinois Department to assure
that such drugs, dentures, prosthetic devices and eyeglasses
for which payment is being made are actually being received by
eligible recipients. Within 90 days after September 16, 1984
(the effective date of Public Act 83-1439), the Illinois
Department shall establish a current list of acquisition costs
for all prosthetic devices and any other items recognized as
medical equipment and supplies reimbursable under this Article

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and shall update such list on a quarterly basis, except that
the acquisition costs of all prescription drugs shall be
updated no less frequently than every 30 days as required by
Section 5-5.12.
Notwithstanding any other law to the contrary, the
Illinois Department shall, within 365 days after July 22, 2013
(the effective date of Public Act 98-104), establish
procedures to permit skilled care facilities licensed under
the Nursing Home Care Act to submit monthly billing claims for
reimbursement purposes. Following development of these
procedures, the Department shall, by July 1, 2016, test the
viability of the new system and implement any necessary
operational or structural changes to its information
technology platforms in order to allow for the direct
acceptance and payment of nursing home claims.
Notwithstanding any other law to the contrary, the
Illinois Department shall, within 365 days after August 15,
2014 (the effective date of Public Act 98-963), establish
procedures to permit ID/DD facilities licensed under the ID/DD
Community Care Act and MC/DD facilities licensed under the
MC/DD Act to submit monthly billing claims for reimbursement
purposes. Following development of these procedures, the
Department shall have an additional 365 days to test the
viability of the new system and to ensure that any necessary
operational or structural changes to its information
technology platforms are implemented.

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The Illinois Department shall require all dispensers of
medical services, other than an individual practitioner or
group of practitioners, desiring to participate in the Medical
Assistance program established under this Article to disclose
all financial, beneficial, ownership, equity, surety or other
interests in any and all firms, corporations, partnerships,
associations, business enterprises, joint ventures, agencies,
institutions or other legal entities providing any form of
health care services in this State under this Article.
The Illinois Department may require that all dispensers of
medical services desiring to participate in the medical
assistance program established under this Article disclose,
under such terms and conditions as the Illinois Department may
by rule establish, all inquiries from clients and attorneys
regarding medical bills paid by the Illinois Department, which
inquiries could indicate potential existence of claims or
liens for the Illinois Department.
Enrollment of a vendor shall be subject to a provisional
period and shall be conditional for one year. During the
period of conditional enrollment, the Department may terminate
the vendor's eligibility to participate in, or may disenroll
the vendor from, the medical assistance program without cause.
Unless otherwise specified, such termination of eligibility or
disenrollment is not subject to the Department's hearing
process. However, a disenrolled vendor may reapply without
penalty.

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The Department has the discretion to limit the conditional
enrollment period for vendors based upon the category of risk
of the vendor.
Prior to enrollment and during the conditional enrollment
period in the medical assistance program, all vendors shall be
subject to enhanced oversight, screening, and review based on
the risk of fraud, waste, and abuse that is posed by the
category of risk of the vendor. The Illinois Department shall
establish the procedures for oversight, screening, and review,
which may include, but need not be limited to: criminal and
financial background checks; fingerprinting; license,
certification, and authorization verifications; unscheduled or
unannounced site visits; database checks; prepayment audit
reviews; audits; payment caps; payment suspensions; and other
screening as required by federal or State law.
The Department shall define or specify the following: (i)
by provider notice, the "category of risk of the vendor" for
each type of vendor, which shall take into account the level of
screening applicable to a particular category of vendor under
federal law and regulations; (ii) by rule or provider notice,
the maximum length of the conditional enrollment period for
each category of risk of the vendor; and (iii) by rule, the
hearing rights, if any, afforded to a vendor in each category
of risk of the vendor that is terminated or disenrolled during
the conditional enrollment period.
To be eligible for payment consideration, a vendor's

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payment claim or bill, either as an initial claim or as a
resubmitted claim following prior rejection, must be received
by the Illinois Department, or its fiscal intermediary, no
later than 180 days after the latest date on the claim on which
medical goods or services were provided, with the following
exceptions:
(1) In the case of a provider whose enrollment is in
process by the Illinois Department, the 180-day period
shall not begin until the date on the written notice from
the Illinois Department that the provider enrollment is
complete.
(2) In the case of errors attributable to the Illinois
Department or any of its claims processing intermediaries
which result in an inability to receive, process, or
adjudicate a claim, the 180-day period shall not begin
until the provider has been notified of the error.
(3) In the case of a provider for whom the Illinois
Department initiates the monthly billing process.
(4) In the case of a provider operated by a unit of
local government with a population exceeding 3,000,000
when local government funds finance federal participation
for claims payments.
For claims for services rendered during a period for which
a recipient received retroactive eligibility, claims must be
filed within 180 days after the Department determines the
applicant is eligible. For claims for which the Illinois

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Department is not the primary payer, claims must be submitted
to the Illinois Department within 180 days after the final
adjudication by the primary payer.
In the case of long term care facilities, within 120
calendar days of receipt by the facility of required
prescreening information, new admissions with associated
admission documents shall be submitted through the Medical
Electronic Data Interchange (MEDI) or the Recipient
Eligibility Verification (REV) System or shall be submitted
directly to the Department of Human Services using required
admission forms. Effective September 1, 2014, admission
documents, including all prescreening information, must be
submitted through MEDI or REV. Confirmation numbers assigned
to an accepted transaction shall be retained by a facility to
verify timely submittal. Once an admission transaction has
been completed, all resubmitted claims following prior
rejection are subject to receipt no later than 180 days after
the admission transaction has been completed.
Claims that are not submitted and received in compliance
with the foregoing requirements shall not be eligible for
payment under the medical assistance program, and the State
shall have no liability for payment of those claims.
To the extent consistent with applicable information and
privacy, security, and disclosure laws, State and federal
agencies and departments shall provide the Illinois Department
access to confidential and other information and data

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necessary to perform eligibility and payment verifications and
other Illinois Department functions. This includes, but is not
limited to: information pertaining to licensure;
certification; earnings; immigration status; citizenship; wage
reporting; unearned and earned income; pension income;
employment; supplemental security income; social security
numbers; National Provider Identifier (NPI) numbers; the
National Practitioner Data Bank (NPDB); program and agency
exclusions; taxpayer identification numbers; tax delinquency;
corporate information; and death records.
The Illinois Department shall enter into agreements with
State agencies and departments, and is authorized to enter
into agreements with federal agencies and departments, under
which such agencies and departments shall share data necessary
for medical assistance program integrity functions and
oversight. The Illinois Department shall develop, in
cooperation with other State departments and agencies, and in
compliance with applicable federal laws and regulations,
appropriate and effective methods to share such data. At a
minimum, and to the extent necessary to provide data sharing,
the Illinois Department shall enter into agreements with State
agencies and departments, and is authorized to enter into
agreements with federal agencies and departments, including,
but not limited to: the Secretary of State; the Department of
Revenue; the Department of Public Health; the Department of
Human Services; and the Department of Financial and

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Professional Regulation.
Beginning in fiscal year 2013, the Illinois Department
shall set forth a request for information to identify the
benefits of a pre-payment, post-adjudication, and post-edit
claims system with the goals of streamlining claims processing
and provider reimbursement, reducing the number of pending or
rejected claims, and helping to ensure a more transparent
adjudication process through the utilization of: (i) provider
data verification and provider screening technology; and (ii)
clinical code editing; and (iii) pre-pay, pre-adjudicated, or
post-adjudicated predictive modeling with an integrated case
management system with link analysis. Such a request for
information shall not be considered as a request for proposal
or as an obligation on the part of the Illinois Department to
take any action or acquire any products or services.
The Illinois Department shall establish policies,
procedures, standards and criteria by rule for the
acquisition, repair and replacement of orthotic and prosthetic
devices and durable medical equipment. Such rules shall
provide, but not be limited to, the following services: (1)
immediate repair or replacement of such devices by recipients;
and (2) rental, lease, purchase or lease-purchase of durable
medical equipment in a cost-effective manner, taking into
consideration the recipient's medical prognosis, the extent of
the recipient's needs, and the requirements and costs for
maintaining such equipment. Subject to prior approval, such

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rules shall enable a recipient to temporarily acquire and use
alternative or substitute devices or equipment pending repairs
or replacements of any device or equipment previously
authorized for such recipient by the Department.
Notwithstanding any provision of Section 5-5f to the contrary,
the Department may, by rule, exempt certain replacement
wheelchair parts from prior approval and, for wheelchairs,
wheelchair parts, wheelchair accessories, and related seating
and positioning items, determine the wholesale price by
methods other than actual acquisition costs.
The Department shall require, by rule, all providers of
durable medical equipment to be accredited by an accreditation
organization approved by the federal Centers for Medicare and
Medicaid Services and recognized by the Department in order to
bill the Department for providing durable medical equipment to
recipients. No later than 15 months after the effective date
of the rule adopted pursuant to this paragraph, all providers
must meet the accreditation requirement.
In order to promote environmental responsibility, meet the
needs of recipients and enrollees, and achieve significant
cost savings, the Department, or a managed care organization
under contract with the Department, may provide recipients or
managed care enrollees who have a prescription or Certificate
of Medical Necessity access to refurbished durable medical
equipment under this Section (excluding prosthetic and
orthotic devices as defined in the Orthotics, Prosthetics, and

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Pedorthics Practice Act and complex rehabilitation technology
products and associated services) through the State's
assistive technology program's reutilization program, using
staff with the Assistive Technology Professional (ATP)
Certification if the refurbished durable medical equipment:
(i) is available; (ii) is less expensive, including shipping
costs, than new durable medical equipment of the same type;
(iii) is able to withstand at least 3 years of use; (iv) is
cleaned, disinfected, sterilized, and safe in accordance with
federal Food and Drug Administration regulations and guidance
governing the reprocessing of medical devices in health care
settings; and (v) equally meets the needs of the recipient or
enrollee. The reutilization program shall confirm that the
recipient or enrollee is not already in receipt of the same or
similar equipment from another service provider, and that the
refurbished durable medical equipment equally meets the needs
of the recipient or enrollee. Nothing in this paragraph shall
be construed to limit recipient or enrollee choice to obtain
new durable medical equipment or place any additional prior
authorization conditions on enrollees of managed care
organizations.
The Department shall execute, relative to the nursing home
prescreening project, written inter-agency agreements with the
Department of Human Services and the Department on Aging, to
effect the following: (i) intake procedures and common
eligibility criteria for those persons who are receiving

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non-institutional services; and (ii) the establishment and
development of non-institutional services in areas of the
State where they are not currently available or are
undeveloped; and (iii) notwithstanding any other provision of
law, subject to federal approval, on and after July 1, 2012, an
increase in the determination of need (DON) scores from 29 to
37 for applicants for institutional and home and
community-based long term care; if and only if federal
approval is not granted, the Department may, in conjunction
with other affected agencies, implement utilization controls
or changes in benefit packages to effectuate a similar savings
amount for this population; and (iv) no later than July 1,
2013, minimum level of care eligibility criteria for
institutional and home and community-based long term care; and
(v) no later than October 1, 2013, establish procedures to
permit long term care providers access to eligibility scores
for individuals with an admission date who are seeking or
receiving services from the long term care provider. In order
to select the minimum level of care eligibility criteria, the
Governor shall establish a workgroup that includes affected
agency representatives and stakeholders representing the
institutional and home and community-based long term care
interests. This Section shall not restrict the Department from
implementing lower level of care eligibility criteria for
community-based services in circumstances where federal
approval has been granted.

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The Illinois Department shall develop and operate, in
cooperation with other State Departments and agencies and in
compliance with applicable federal laws and regulations,
appropriate and effective systems of health care evaluation
and programs for monitoring of utilization of health care
services and facilities, as it affects persons eligible for
medical assistance under this Code.
The Illinois Department shall report annually to the
General Assembly, no later than the second Friday in April of
1979 and each year thereafter, in regard to:
(a) actual statistics and trends in utilization of
medical services by public aid recipients;
(b) actual statistics and trends in the provision of
the various medical services by medical vendors;
(c) current rate structures and proposed changes in
those rate structures for the various medical vendors; and
(d) efforts at utilization review and control by the
Illinois Department.
The period covered by each report shall be the 3 years
ending on the June 30 prior to the report. The report shall
include suggested legislation for consideration by the General
Assembly. The requirement for reporting to the General
Assembly shall be satisfied by filing copies of the report as
required by Section 3.1 of the General Assembly Organization
Act, and filing such additional copies with the State
Government Report Distribution Center for the General Assembly

10400SB3365ham001 - 32 - LRB104 18483 KTG 38682 a
as is required under paragraph (t) of Section 7 of the State
Library Act.
Rulemaking authority to implement Public Act 95-1045, if
any, is conditioned on the rules being adopted in accordance
with all provisions of the Illinois Administrative Procedure
Act and all rules and procedures of the Joint Committee on
Administrative Rules; any purported rule not so adopted, for
whatever reason, is unauthorized.
On and after July 1, 2012, the Department shall reduce any
rate of reimbursement for services or other payments or alter
any methodologies authorized by this Code to reduce any rate
of reimbursement for services or other payments in accordance
with Section 5-5e.
Because kidney transplantation can be an appropriate,
cost-effective alternative to renal dialysis when medically
necessary and notwithstanding the provisions of Section 1-11
of this Code, beginning October 1, 2014, the Department shall
cover kidney transplantation for noncitizens with end-stage
renal disease who are not eligible for comprehensive medical
benefits, who meet the residency requirements of Section 5-3
of this Code, and who would otherwise meet the financial
requirements of the appropriate class of eligible persons
under Section 5-2 of this Code. To qualify for coverage of
kidney transplantation, such person must be receiving
emergency renal dialysis services covered by the Department.
Providers under this Section shall be prior approved and

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certified by the Department to perform kidney transplantation
and the services under this Section shall be limited to
services associated with kidney transplantation.
Notwithstanding any other provision of this Code to the
contrary, on or after July 1, 2015, all FDA-approved forms of
medication assisted treatment prescribed for the treatment of
alcohol dependence or treatment of opioid dependence shall be
covered under both fee-for-service and managed care medical
assistance programs for persons who are otherwise eligible for
medical assistance under this Article and shall not be subject
to any (1) utilization control, other than those established
under the American Society of Addiction Medicine patient
placement criteria, (2) prior authorization mandate, (3)
lifetime restriction limit mandate, or (4) limitations on
dosage.
On or after July 1, 2015, opioid antagonists prescribed
for the treatment of an opioid overdose, including the
medication product, administration devices, and any pharmacy
fees or hospital fees related to the dispensing, distribution,
and administration of the opioid antagonist, shall be covered
under the medical assistance program for persons who are
otherwise eligible for medical assistance under this Article.
As used in this Section, "opioid antagonist" means a drug that
binds to opioid receptors and blocks or inhibits the effect of
opioids acting on those receptors, including, but not limited
to, naloxone hydrochloride or any other similarly acting drug

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approved by the U.S. Food and Drug Administration. The
Department shall not impose a copayment on the coverage
provided for naloxone hydrochloride under the medical
assistance program.
Upon federal approval, the Department shall provide
coverage and reimbursement for all drugs that are approved for
marketing by the federal Food and Drug Administration and that
are recommended by the federal Public Health Service or the
United States Centers for Disease Control and Prevention for
pre-exposure prophylaxis and related pre-exposure prophylaxis
services, including, but not limited to, HIV and sexually
transmitted infection screening, treatment for sexually
transmitted infections, medical monitoring, assorted labs, and
counseling to reduce the likelihood of HIV infection among
individuals who are not infected with HIV but who are at high
risk of HIV infection.
A federally qualified health center, as defined in Section
1905(l)(2)(B) of the federal Social Security Act, shall be
reimbursed by the Department in accordance with the federally
qualified health center's encounter rate for services provided
to medical assistance recipients that are performed by a
dental hygienist, as defined under the Illinois Dental
Practice Act, working under the general supervision of a
dentist and employed by a federally qualified health center.
Within 90 days after October 8, 2021 (the effective date
of Public Act 102-665), the Department shall seek federal

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approval of a State Plan amendment to expand coverage for
family planning services that includes presumptive eligibility
to individuals whose income is at or below 208% of the federal
poverty level. Coverage under this Section shall be effective
beginning no later than December 1, 2022.
Subject to approval by the federal Centers for Medicare
and Medicaid Services of a Title XIX State Plan amendment
electing the Program of All-Inclusive Care for the Elderly
(PACE) as a State Medicaid option, as provided for by Subtitle
I (commencing with Section 4801) of Title IV of the Balanced
Budget Act of 1997 (Public Law 105-33) and Part 460
(commencing with Section 460.2) of Subchapter E of Title 42 of
the Code of Federal Regulations, PACE program services shall
become a covered benefit of the medical assistance program,
subject to criteria established in accordance with all
applicable laws.
Notwithstanding any other provision of this Code,
community-based pediatric palliative care from a trained
interdisciplinary team shall be covered under the medical
assistance program as provided in Section 15 of the Pediatric
Palliative Care Act.
Notwithstanding any other provision of this Code, within
12 months after June 2, 2022 (the effective date of Public Act
102-1037) and subject to federal approval, acupuncture
services performed by an acupuncturist licensed under the
Acupuncture Practice Act who is acting within the scope of his

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or her license shall be covered under the medical assistance
program. The Department shall apply for any federal waiver or
State Plan amendment, if required, to implement this
paragraph. The Department may adopt any rules, including
standards and criteria, necessary to implement this paragraph.
Notwithstanding any other provision of this Code, the
medical assistance program shall, subject to federal approval,
reimburse hospitals for costs associated with a newborn
screening test for the presence of metachromatic
leukodystrophy, as required under the Newborn Metabolic
Screening Act, at a rate not less than the fee charged by the
Department of Public Health. Notwithstanding any other
provision of this Code, the medical assistance program shall,
subject to appropriation and federal approval, also reimburse
hospitals for costs associated with all newborn screening
tests added on and after August 9, 2024 (the effective date of
Public Act 103-909) to the Newborn Metabolic Screening Act and
required to be performed under that Act at a rate not less than
the fee charged by the Department of Public Health. The
Department shall seek federal approval before the
implementation of the newborn screening test fees by the
Department of Public Health.
Notwithstanding any other provision of this Code,
beginning on January 1, 2024, subject to federal approval,
cognitive assessment and care planning services provided to a
person who experiences signs or symptoms of cognitive

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impairment, as defined by the Diagnostic and Statistical
Manual of Mental Disorders, Fifth Edition, shall be covered
under the medical assistance program for persons who are
otherwise eligible for medical assistance under this Article.
Notwithstanding any other provision of this Code,
medically necessary reconstructive services that are intended
to restore physical appearance shall be covered under the
medical assistance program for persons who are otherwise
eligible for medical assistance under this Article. As used in
this paragraph, "reconstructive services" means treatments
performed on structures of the body damaged by trauma to
restore physical appearance.
Subject to federal approval, for dates of services on and
after January 1, 2026, over-the-counter choline dietary
supplements for pregnant persons shall be covered under the
medical assistance program.
(Source: P.A. 103-102, Article 15, Section 15-5, eff. 1-1-24;
103-102, Article 95, Section 95-15, eff. 1-1-24; 103-123, eff.
1-1-24; 103-154, eff. 6-30-23; 103-368, eff. 1-1-24; 103-593,
Article 5, Section 5-5, eff. 6-7-24; 103-593, Article 90,
Section 90-5, eff. 6-7-24; 103-605, eff. 7-1-24; 103-808, eff.
1-1-26; 103-909, eff. 8-9-24; 103-1040, eff. 8-9-24; 104-9,
eff. 6-16-25; 104-417, eff. 8-15-25.)
ARTICLE 6.

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Section 6-5. The Illinois Public Aid Code is amended by
adding Article V-J as follows:
(305 ILCS 5/Art. V-J heading new)
ARTICLE V-J. DISTRESSED HOSPITAL LOAN PROGRAM
(305 ILCS 5/5J-1 new)
Sec. 5J-1. References to Article. This Article may be
referred to as the Distressed Hospital Loan Program Law.
(305 ILCS 5/5J-5 new)
Sec. 5J-5. Distressed Hospital Loan Program. The
Distressed Hospital Loan Program is created. The purpose of
the Program is to provide, subject to appropriation and the
availability of funds, interest-free cash flow loans to
public, not-for-profit, and for-profit hospitals in
significant financial distress to prevent the closure of or to
facilitate the reopening of those hospitals.
(305 ILCS 5/5J-10 new)
Sec. 5J-10. Definitions. As used in this Article:
"Closed hospital" means a hospital that closed after
January 1, 2019.
"Department" means the Department of Healthcare and Family
Services.
"Program" means the Distressed Hospital Loan Program.

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"Public hospital" means a hospital that is licensed by the
Hospital Licensing Act and is either owned or operated by a
governmental body in Illinois, excluding a State agency, a
State university, or a county with a population of 3,000,000
or more.
(305 ILCS 5/5J-15 new)
Sec. 5J-15. Administration. The Department shall
administer the Distressed Hospital Loan Program in
coordination with the Department of Public Health and the
Governor's Office of Management and Budget. The Department
shall adopt rules to implement this Program.
(305 ILCS 5/5J-18 new)
Sec. 5J-18. Application requirements. A hospital applying
for aid under this Program shall provide the Department with
financial information, in a format determined by the
Department, demonstrating the hospital's need for bridge
financing due to financial hardship.
(1) Before receiving bridge financing under this
Program, an eligible hospital shall submit a plan to the
Department, with projections detailing the uses of the
proposed loan and a structured plan proposed by the
hospital's governing body to regain financial viability
and continue operations.
(2) Before issuing a loan under this Program, the

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Department shall review the plan submitted by an eligible
hospital and make a determination both that the plan is
viable and that there is a reasonable likelihood that the
hospital will be able to regain financial viability,
continue to operate as a hospital, and be able to repay the
loan. The Department shall not issue a loan award if the
Department is unable to make these determinations.
(3) All funds loaned in accordance with this Article
shall be used as described in the application approved by
the Department, which shall be incorporated into any
resulting loan agreement. Any misused funds shall be
recouped by the Department subject to the recoupment
methods under Section 5J-25. In addition to any other
remedies provided for by law and without sending a notice
of liability, the Department may withhold, as payment of
any amounts due and owing as repayment of loans issued in
accordance with this Article, reimbursements or other
amounts otherwise payable by the Department to the loan
recipient, including, but not limited to, amounts
otherwise payable from a managed care organization
performing duties under contract with the Department.
(305 ILCS 5/5J-20 new)
Sec. 5J-20. Application evaluation.
(a) In collaboration with the Governor's Office of
Management and Budget and the Department of Public Health, the

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Department shall develop a methodology to evaluate a
hospital's application for a loan through the Program.
(b) The methodology shall consider factors including, but
not limited to, whether the hospital is in financial distress
as solely determined by the State; whether the hospital is
small, rural, a safety-net hospital, a critical access
hospital, a trauma center, an urban hospital providing access
for an underserved area, a hospital that serves a
disproportionate share of Medicaid patients, or serving a
rural catchment area; and whether closure of the hospital or
service line reduction as a result of the financial distress
would significantly impact access to services in the
hospital's health service area.
(c) The methodology for determining financial distress may
consider such factors as the hospital's prior and projected
performance on financial metrics, including the amount of cash
on hand, and whether the hospital has experienced, or is
projected to experience, negative operating margins.
(d) Subject to appropriation and the availability of
funds, any loan to a hospital with an approved loan
application shall be issued as soon as reasonably practicable
following approval of an application. Approved applications
shall receive funding on a first-come, first-served basis
until funding appropriated by the General Assembly for this
purpose has been expended. The Department maintains discretion
to determine the amount of a loan approved for a hospital and

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may approve less than the amount requested by a hospital. The
Department may consider the amount of appropriations available
to this Program in the exercise of its discretion.
(e) Hospitals ineligible for State assistance under the
Program include:
(1) Hospitals that belong to integrated health care
systems with more than 3 separately licensed hospital
facilities.
(2) A hospital that maintains unpaid hospital
assessment liability owed to the State and either does not
have a negotiated tax repayment agreement with the State
or is delinquent under an existing negotiated assessment
repayment agreement.
(3) A hospital that is not current on a repayment
schedule for a prior advance issued in accordance with 89
Ill. Adm. Code 140.71.
(4) A hospital that has not provided required
reporting on its finances as mandated by State law or
administrative rule.
(5) A hospital that is subject to a stop payment
order, as defined by the Grant Accountability and
Transparency Act, with the State for any reason.
(6) A hospital that has been under investigation or
been issued an immediate jeopardy by the Centers for
Medicare and Medicaid Services in the prior 12 months from
the time of loan application.

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(f) The Department shall give preference to not-for-profit
and public hospitals. Hospitals owned and operated by a
for-profit entity shall be subject to a maximum funding limit,
expedited repayment time frames, and additional financial and
operational transparency requirements as defined in rule.
(g) The Department shall determine the application
process, underwriting review, and methodology for approval and
distribution of the loans under the Program.
(h) The Department shall have the authority to determine
service provision requirements in approving, and for the
duration of, loans to eligible hospitals. In making its
determination, the Department shall consider the impact of any
changes to the hospital's service delivery or access to
necessary medical care, particularly for beneficiaries of the
State's medical assistance Program.
(i) The application process shall allow for at least 30
days for the Department to issue an initial response to any
loan application.
(305 ILCS 5/5J-25 new)
Sec. 5J-25. Repayment agreement.
(a) A hospital shall be required to enter into a repayment
agreement with the Department to execute the approved loan.
Terms must include, but are not limited to, monthly repayments
of the loan beginning no later than 18 months after receipt of
the loan and discharge of the loan within 36 months of the date

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of the loan.
(b) Notwithstanding any other law and to the extent
permissible under federal rules, security for the cash flow
loans in this Article shall, at a minimum, include
reimbursements due to the hospital from the Department,
including, but not limited to, any reimbursements under this
Code. The repayment agreement may provide for additional
security for any cash flow loans under this Article.
(c) If the hospital provider fails to comply with the
repayment terms of the agreement, the remaining balance of the
loan shall be immediately recouped from reimbursements or
other amounts otherwise payable by the Department to the loan
recipient, including, but not limited to, amounts otherwise
payable from a managed care organization performing duties
under contract with the Department. The Department may also
recoup amounts otherwise payable by any State agency to the
provider, including, but not limited to, State grants and
grant appropriations, and apply such amounts as repayment of
the unpaid advance. If such reimbursements or other amounts
otherwise payable to the loan recipient are insufficient for
complete recovery, the remaining balance shall become
immediately due and payable by check to the Department of
Healthcare and Family Services. Failure by the provider to
remit such check shall result in the Department pursuing other
collection methods.
(d) Any unpaid loan under this Article shall become a lien

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upon the assets of the hospital that received the loan. If any
hospital provider, outside the usual course of its business,
sells or transfers the major part of any one or more of (A) the
real property and improvements, (B) the machinery and
equipment, or (C) the furniture or fixtures, of any hospital
that is subject to the provisions of this Article, the seller
or transferor shall pay the Department the amount of any loan,
penalty, and interest (if any) due from it under this Article
up to the date of the sale or transfer. The Department may, in
its discretion, foreclose on such a lien, but shall do so in a
manner that is consistent with Section 5e of the Retailers'
Occupation Tax Act. If the seller or transferor fails to pay
any loan, penalty, and interest (if any) due, the purchaser or
transferee of such asset shall be liable for the amount of the
loan, penalties, and interest (if any) up to the amount of the
reasonable value of the property acquired by the purchaser or
transferee. The purchaser or transferee shall continue to be
liable until the purchaser or transferee pays the full amount
of the loan, penalties, and interest (if any) up to the amount
of the reasonable value of the property acquired by the
purchaser or transferee or until the purchaser or transferee
receives from the Department a certificate showing that such
loan, penalty, and interest have been paid or a certificate
from the Department showing that no loan, penalty, or interest
is due from the seller or transferor under this Article.
(e) If a hospital provider fails to pay any monthly

10400SB3365ham001 - 46 - LRB104 18483 KTG 38682 a
installment repayments, there shall, unless waived by the
Department for reasonable cause, be added to the loan
repayment obligation a penalty equal to the lesser of (i) 5% of
the amount of the installment not paid on or before the due
date plus 5% of the portion thereof remaining unpaid on the
last day of each 30-day period thereafter or (ii) 100% of the
installment amount not paid on or before the due date.
(305 ILCS 5/5J-30 new)
Sec. 5J-30. Distressed Hospital Loan Program Fund.
(a) The Distressed Hospital Loan Program Fund is created
as a special fund in the State treasury.
(b) Subject to appropriation, the Department may make
secured and unsecured loans from amounts in the Distressed
Hospital Loan Program Fund to a hospital, or a governmental
entity representing a closed hospital, for purposes of
preventing the hospital's closure in accordance with the
provisions of this Article.
(c) On January 1, 2027, or as soon thereafter as
practical, the State Comptroller shall direct and the State
Treasurer shall transfer, at the direction of the Director of
the Department, an amount not to exceed $85,000,000 from the
Healthcare Provider Relief Fund to the Distressed Hospital
Loan Program Fund.
(d) All moneys accruing to the Department under this
Article from any source, including, but not limited to, all

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amounts repaid under the terms of any loan agreements, shall
be deposited into the Fund.
(e) On June 30, 2033, or as soon thereafter as practical,
the State Comptroller shall direct and the State Treasurer
shall transfer the remaining balance in the Distressed
Hospital Loan Program Fund to the Healthcare Provider Relief
Fund. Upon completion of the transfers, the Distressed
Hospital Loan Program Fund is dissolved and any outstanding
obligations or liabilities of the Fund pass to the Healthcare
Provider Relief Fund. The Department shall deposit all
subsequent loan repayments or medical assistance program or
other reimbursements withheld for due cause in accordance with
this Article into the Healthcare Provider Relief Fund.
(f) The Department may require any hospital receiving a
loan under this Article to provide the Department with an
independent financial audit of the hospital's operations for
any fiscal year in which a loan is outstanding.
(305 ILCS 5/5J-35 new)
Sec. 5J-35. Implementation. The Program described in this
Article shall be operative on and after January 1, 2027 and
shall be implemented upon administrative rules being in
effect.
(305 ILCS 5/5J-40 new)
Sec. 5J-40. Repealer. This Article is repealed on June 30,

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2033.
Section 6-70. The State Finance Act is amended by adding
Section 5.1038 as follows:
(30 ILCS 105/5.1038 new)
Sec. 5.1038. The Distressed Hospital Loan Program Fund.
This Section is repealed June 30, 2033.
Section 6-72. The Illinois Administrative Procedure Act is
amended by adding Section 5-45.71 as follows:
(5 ILCS 100/5-45.71 new)
Sec. 5-45.71. Emergency rulemaking; Health Facilities and
Services Review Board. To provide for the expeditious and
timely implementation of the changes made by this amendatory
Act of the 104th General Assembly to Section 13 of the Illinois
Health Facilities Planning Act, emergency rules may be adopted
in accordance with Section 5-45 by the Health Facilities and
Services Review Board. The adoption of emergency rules
authorized by Section 5-45 and this Section is deemed to be
necessary for the public interest, safety, and welfare.
This Section is repealed one year after the effective date
of this amendatory Act of the 104th General Assembly.
Section 6-73. The Freedom of Information Act is amended by

10400SB3365ham001 - 49 - LRB104 18483 KTG 38682 a
changing Section 7.5 as follows:
(5 ILCS 140/7.5)
(Text of Section before amendment by P.A. 104-441 and
104-457)
Sec. 7.5. Statutory exemptions. To the extent provided for
by the statutes referenced below, the following shall be
exempt from inspection and copying:
(a) All information determined to be confidential
under Section 4002 of the Technology Advancement and
Development Act.
(b) Library circulation and order records identifying
library users with specific materials under the Library
Records Confidentiality Act.
(c) Applications, related documents, and medical
records received by the Experimental Organ Transplantation
Procedures Board and any and all documents or other
records prepared by the Experimental Organ Transplantation
Procedures Board or its staff relating to applications it
has received.
(d) Information and records held by the Department of
Public Health and its authorized representatives relating
to known or suspected cases of sexually transmitted
infection or any information the disclosure of which is
restricted under the Illinois Sexually Transmitted
Infection Control Act.

10400SB3365ham001 - 50 - LRB104 18483 KTG 38682 a
(e) Information the disclosure of which is exempted
under Section 30 of the Radon Industry Licensing Act.
(f) Firm performance evaluations under Section 55 of
the Architectural, Engineering, and Land Surveying
Qualifications Based Selection Act.
(g) Information the disclosure of which is restricted
and exempted under Section 50 of the Illinois Prepaid
Tuition Act.
(h) Information the disclosure of which is exempted
under the State Officials and Employees Ethics Act, and
records of any lawfully created State or local inspector
general's office that would be exempt if created or
obtained by an Executive Inspector General's office under
that Act.
(i) Information contained in a local emergency energy
plan submitted to a municipality in accordance with a
local emergency energy plan ordinance that is adopted
under Section 11-21.5-5 of the Illinois Municipal Code.
(j) Information and data concerning the distribution
of surcharge moneys collected and remitted by carriers
under the Emergency Telephone System Act.
(k) Law enforcement officer identification information
or driver identification information compiled by a law
enforcement agency or the Department of Transportation
under Section 11-212 of the Illinois Vehicle Code.
(l) Records and information provided to a residential

10400SB3365ham001 - 51 - LRB104 18483 KTG 38682 a
health care facility resident sexual assault and death
review team or the Executive Council under the Abuse
Prevention Review Team Act.
(m) Information provided to the predatory lending
database created pursuant to Article 3 of the Residential
Real Property Disclosure Act, except to the extent
authorized under that Article.
(n) Defense budgets and petitions for certification of
compensation and expenses for court appointed trial
counsel as provided under Sections 10 and 15 of the
Capital Crimes Litigation Act (repealed). This subsection
(n) shall apply until the conclusion of the trial of the
case, even if the prosecution chooses not to pursue the
death penalty prior to trial or sentencing.
(o) Information that is prohibited from being
disclosed under Section 4 of the Illinois Health and
Hazardous Substances Registry Act.
(p) Security portions of system safety program plans,
investigation reports, surveys, schedules, lists, data, or
information compiled, collected, or prepared by or for the
Department of Transportation under Sections 2705-300 and
2705-616 of the Department of Transportation Law of the
Civil Administrative Code of Illinois, the Regional
Transportation Authority under Section 2.11 of the
Regional Transportation Authority Act, or the St. Clair
County Transit District under the Bi-State Transit Safety

10400SB3365ham001 - 52 - LRB104 18483 KTG 38682 a
Act (repealed).
(q) Information prohibited from being disclosed by the
Personnel Record Review Act.
(r) Information prohibited from being disclosed by the
Illinois School Student Records Act.
(s) Information the disclosure of which is restricted
under Section 5-108 of the Public Utilities Act.
(t) (Blank).
(u) Records and information provided to an independent
team of experts under the Developmental Disability and
Mental Health Safety Act (also known as Brian's Law).
(v) Names and information of people who have applied
for or received Firearm Owner's Identification Cards under
the Firearm Owners Identification Card Act or applied for
or received a concealed carry license under the Firearm
Concealed Carry Act, unless otherwise authorized by the
Firearm Concealed Carry Act; and databases under the
Firearm Concealed Carry Act, records of the Concealed
Carry Licensing Review Board under the Firearm Concealed
Carry Act, and law enforcement agency objections under the
Firearm Concealed Carry Act.
(v-5) Records of the Firearm Owner's Identification
Card Review Board that are exempted from disclosure under
Section 10 of the Firearm Owners Identification Card Act.
(w) Personally identifiable information which is
exempted from disclosure under subsection (g) of Section

10400SB3365ham001 - 53 - LRB104 18483 KTG 38682 a
19.1 of the Toll Highway Act.
(x) Information which is exempted from disclosure
under Section 5-1014.3 of the Counties Code or Section
8-11-21 of the Illinois Municipal Code.
(y) Confidential information under the Adult
Protective Services Act and its predecessor enabling
statute, the Elder Abuse and Neglect Act, including
information about the identity and administrative finding
against any caregiver of a verified and substantiated
decision of abuse, neglect, or financial exploitation of
an eligible adult maintained in the Registry established
under Section 7.5 of the Adult Protective Services Act.
(z) Records and information provided to a fatality
review team or the Illinois Fatality Review Team Advisory
Council under Section 15 of the Adult Protective Services
Act.
(aa) Information which is exempted from disclosure
under Section 2.37 of the Wildlife Code.
(bb) Information which is or was prohibited from
disclosure by the Juvenile Court Act of 1987.
(cc) Recordings made under the Law Enforcement
Officer-Worn Body Camera Act, except to the extent
authorized under that Act.
(dd) Information that is prohibited from being
disclosed under Section 45 of the Condominium and Common
Interest Community Ombudsperson Act.

10400SB3365ham001 - 54 - LRB104 18483 KTG 38682 a
(ee) Information that is exempted from disclosure
under Section 30.1 of the Pharmacy Practice Act.
(ff) Information that is exempted from disclosure
under the Revised Uniform Unclaimed Property Act.
(gg) Information that is prohibited from being
disclosed under Section 7-603.5 of the Illinois Vehicle
Code.
(hh) Records that are exempt from disclosure under
Section 1A-16.7 of the Election Code.
(ii) Information which is exempted from disclosure
under Section 2505-800 of the Department of Revenue Law of
the Civil Administrative Code of Illinois.
(jj) Information and reports that are required to be
submitted to the Department of Labor by registering day
and temporary labor service agencies but are exempt from
disclosure under subsection (a-1) of Section 45 of the Day
and Temporary Labor Services Act.
(kk) Information prohibited from disclosure under the
Seizure and Forfeiture Reporting Act.
(ll) Information the disclosure of which is restricted
and exempted under Section 5-30.8 of the Illinois Public
Aid Code.
(mm) Records that are exempt from disclosure under
Section 4.2 of the Crime Victims Compensation Act.
(nn) Information that is exempt from disclosure under
Section 70 of the Higher Education Student Assistance Act.

10400SB3365ham001 - 55 - LRB104 18483 KTG 38682 a
(oo) Communications, notes, records, and reports
arising out of a peer support counseling session
prohibited from disclosure under the First Responders
Suicide Prevention Act.
(pp) Names and all identifying information relating to
an employee of an emergency services provider or law
enforcement agency under the First Responders Suicide
Prevention Act.
(qq) Information and records held by the Department of
Public Health and its authorized representatives collected
under the Reproductive Health Act.
(rr) Information that is exempt from disclosure under
the Cannabis Regulation and Tax Act.
(ss) Data reported by an employer to the Department of
Human Rights pursuant to Section 2-108 of the Illinois
Human Rights Act.
(tt) Recordings made under the Children's Advocacy
Center Act, except to the extent authorized under that
Act.
(uu) Information that is exempt from disclosure under
Section 50 of the Sexual Assault Evidence Submission Act.
(vv) Information that is exempt from disclosure under
subsections (f) and (j) of Section 5-36 of the Illinois
Public Aid Code.
(ww) Information that is exempt from disclosure under
Section 16.8 of the State Treasurer Act.

10400SB3365ham001 - 56 - LRB104 18483 KTG 38682 a
(xx) Information that is exempt from disclosure or
information that shall not be made public under the
Illinois Insurance Code.
(yy) Information prohibited from being disclosed under
the Illinois Educational Labor Relations Act.
(zz) Information prohibited from being disclosed under
the Illinois Public Labor Relations Act.
(aaa) Information prohibited from being disclosed
under Section 1-167 of the Illinois Pension Code.
(bbb) Information that is prohibited from disclosure
by the Illinois Police Training Act and the Illinois State
Police Act.
(ccc) Records exempt from disclosure under Section
2605-304 of the Illinois State Police Law of the Civil
Administrative Code of Illinois.
(ddd) Information prohibited from being disclosed
under Section 35 of the Address Confidentiality for
Victims of Domestic Violence, Sexual Assault, Human
Trafficking, or Stalking Act.
(eee) Information prohibited from being disclosed
under subsection (b) of Section 75 of the Domestic
Violence Fatality Review Act.
(fff) Images from cameras under the Expressway Camera
Act and all automated license plate reader (ALPR)
information used and collected by the Illinois State
Police. "ALPR information" means information gathered by

10400SB3365ham001 - 57 - LRB104 18483 KTG 38682 a
an ALPR or created from the analysis of data generated by
an ALPR. This subsection (fff) is inoperative on and after
July 1, 2028.
(ggg) Information prohibited from disclosure under
paragraph (3) of subsection (a) of Section 14 of the Nurse
Agency Licensing Act.
(hhh) Information submitted to the Illinois State
Police in an affidavit or application for an assault
weapon endorsement, assault weapon attachment endorsement,
.50 caliber rifle endorsement, or .50 caliber cartridge
endorsement under the Firearm Owners Identification Card
Act.
(iii) Data exempt from disclosure under Section 50 of
the School Safety Drill Act.
(jjj) Information exempt from disclosure under Section
30 of the Insurance Data Security Law.
(kkk) Confidential business information prohibited
from disclosure under Section 45 of the Paint Stewardship
Act.
(lll) Data exempt from disclosure under Section
2-3.196 of the School Code.
(mmm) Information prohibited from being disclosed
under subsection (e) of Section 1-129 of the Illinois
Power Agency Act.
(nnn) Materials received by the Department of Commerce
and Economic Opportunity that are confidential under the

10400SB3365ham001 - 58 - LRB104 18483 KTG 38682 a
Music and Musicians Tax Credit and Jobs Act.
(ooo) Data or information provided pursuant to Section
20 of the Statewide Recycling Needs and Assessment Act.
(ppp) Information that is exempt from disclosure under
Section 28-11 of the Lawful Health Care Activity Act.
(qqq) Information that is exempt from disclosure under
Section 7-101 of the Illinois Human Rights Act.
(rrr) Information prohibited from being disclosed
under Section 4-2 of the Uniform Money Transmission
Modernization Act.
(sss) Information exempt from disclosure under Section
40 of the Student-Athlete Endorsement Rights Act.
(ttt) Audio recordings made under Section 30 of the
Illinois State Police Act, except to the extent authorized
under that Section.
(uuu) Information prohibited from being disclosed
under Section 30-5 of the Digital Assets Regulation Act.
(Source: P.A. 103-8, eff. 6-7-23; 103-34, eff. 6-9-23;
103-142, eff. 1-1-24; 103-372, eff. 1-1-24; 103-472, eff.
8-1-24; 103-508, eff. 8-4-23; 103-580, eff. 12-8-23; 103-592,
eff. 6-7-24; 103-605, eff. 7-1-24; 103-636, eff. 7-1-24;
103-724, eff. 1-1-25; 103-786, eff. 8-7-24; 103-859, eff.
8-9-24; 103-991, eff. 8-9-24; 103-1049, eff. 8-9-24; 103-1081,
eff. 3-21-25; 104-10, eff. 6-16-25; 104-18, eff. 6-30-25;
104-417, eff. 8-15-25; 104-428, eff. 8-18-25; revised
9-10-25.)

10400SB3365ham001 - 59 - LRB104 18483 KTG 38682 a
(Text of Section after amendment by P.A. 104-457 but
before 104-441)
Sec. 7.5. Statutory exemptions. To the extent provided for
by the statutes referenced below, the following shall be
exempt from inspection and copying:
(a) All information determined to be confidential
under Section 4002 of the Technology Advancement and
Development Act.
(b) Library circulation and order records identifying
library users with specific materials under the Library
Records Confidentiality Act.
(c) Applications, related documents, and medical
records received by the Experimental Organ Transplantation
Procedures Board and any and all documents or other
records prepared by the Experimental Organ Transplantation
Procedures Board or its staff relating to applications it
has received.
(d) Information and records held by the Department of
Public Health and its authorized representatives relating
to known or suspected cases of sexually transmitted
infection or any information the disclosure of which is
restricted under the Illinois Sexually Transmitted
Infection Control Act.
(e) Information the disclosure of which is exempted
under Section 30 of the Radon Industry Licensing Act.

10400SB3365ham001 - 60 - LRB104 18483 KTG 38682 a
(f) Firm performance evaluations under Section 55 of
the Architectural, Engineering, and Land Surveying
Qualifications Based Selection Act.
(g) Information the disclosure of which is restricted
and exempted under Section 50 of the Illinois Prepaid
Tuition Act.
(h) Information the disclosure of which is exempted
under the State Officials and Employees Ethics Act, and
records of any lawfully created State or local inspector
general's office that would be exempt if created or
obtained by an Executive Inspector General's office under
that Act.
(i) Information contained in a local emergency energy
plan submitted to a municipality in accordance with a
local emergency energy plan ordinance that is adopted
under Section 11-21.5-5 of the Illinois Municipal Code.
(j) Information and data concerning the distribution
of surcharge moneys collected and remitted by carriers
under the Emergency Telephone System Act.
(k) Law enforcement officer identification information
or driver identification information compiled by a law
enforcement agency or the Department of Transportation
under Section 11-212 of the Illinois Vehicle Code.
(l) Records and information provided to a residential
health care facility resident sexual assault and death
review team or the Executive Council under the Abuse

10400SB3365ham001 - 61 - LRB104 18483 KTG 38682 a
Prevention Review Team Act.
(m) Information provided to the predatory lending
database created pursuant to Article 3 of the Residential
Real Property Disclosure Act, except to the extent
authorized under that Article.
(n) Defense budgets and petitions for certification of
compensation and expenses for court appointed trial
counsel as provided under Sections 10 and 15 of the
Capital Crimes Litigation Act (repealed). This subsection
(n) shall apply until the conclusion of the trial of the
case, even if the prosecution chooses not to pursue the
death penalty prior to trial or sentencing.
(o) Information that is prohibited from being
disclosed under Section 4 of the Illinois Health and
Hazardous Substances Registry Act.
(p) Security portions of system safety program plans,
investigation reports, surveys, schedules, lists, data, or
information compiled, collected, or prepared by or for the
Department of Transportation under Sections 2705-300 and
2705-616 of the Department of Transportation Law of the
Civil Administrative Code of Illinois, the Northern
Illinois Transit Authority under Section 2.11 of the
Northern Illinois Transit Authority Act, or the St. Clair
County Transit District under the Bi-State Transit Safety
Act (repealed).
(q) Information prohibited from being disclosed by the

10400SB3365ham001 - 62 - LRB104 18483 KTG 38682 a
Personnel Record Review Act.
(r) Information prohibited from being disclosed by the
Illinois School Student Records Act.
(s) Information the disclosure of which is restricted
under Section 5-108 of the Public Utilities Act.
(t) (Blank).
(u) Records and information provided to an independent
team of experts under the Developmental Disability and
Mental Health Safety Act (also known as Brian's Law).
(v) Names and information of people who have applied
for or received Firearm Owner's Identification Cards under
the Firearm Owners Identification Card Act or applied for
or received a concealed carry license under the Firearm
Concealed Carry Act, unless otherwise authorized by the
Firearm Concealed Carry Act; and databases under the
Firearm Concealed Carry Act, records of the Concealed
Carry Licensing Review Board under the Firearm Concealed
Carry Act, and law enforcement agency objections under the
Firearm Concealed Carry Act.
(v-5) Records of the Firearm Owner's Identification
Card Review Board that are exempted from disclosure under
Section 10 of the Firearm Owners Identification Card Act.
(w) Personally identifiable information which is
exempted from disclosure under subsection (g) of Section
19.1 of the Toll Highway Act.
(x) Information which is exempted from disclosure

10400SB3365ham001 - 63 - LRB104 18483 KTG 38682 a
under Section 5-1014.3 of the Counties Code or Section
8-11-21 of the Illinois Municipal Code.
(y) Confidential information under the Adult
Protective Services Act and its predecessor enabling
statute, the Elder Abuse and Neglect Act, including
information about the identity and administrative finding
against any caregiver of a verified and substantiated
decision of abuse, neglect, or financial exploitation of
an eligible adult maintained in the Registry established
under Section 7.5 of the Adult Protective Services Act.
(z) Records and information provided to a fatality
review team or the Illinois Fatality Review Team Advisory
Council under Section 15 of the Adult Protective Services
Act.
(aa) Information which is exempted from disclosure
under Section 2.37 of the Wildlife Code.
(bb) Information which is or was prohibited from
disclosure by the Juvenile Court Act of 1987.
(cc) Recordings made under the Law Enforcement
Officer-Worn Body Camera Act, except to the extent
authorized under that Act.
(dd) Information that is prohibited from being
disclosed under Section 45 of the Condominium and Common
Interest Community Ombudsperson Act.
(ee) Information that is exempted from disclosure
under Section 30.1 of the Pharmacy Practice Act.

10400SB3365ham001 - 64 - LRB104 18483 KTG 38682 a
(ff) Information that is exempted from disclosure
under the Revised Uniform Unclaimed Property Act.
(gg) Information that is prohibited from being
disclosed under Section 7-603.5 of the Illinois Vehicle
Code.
(hh) Records that are exempt from disclosure under
Section 1A-16.7 of the Election Code.
(ii) Information which is exempted from disclosure
under Section 2505-800 of the Department of Revenue Law of
the Civil Administrative Code of Illinois.
(jj) Information and reports that are required to be
submitted to the Department of Labor by registering day
and temporary labor service agencies but are exempt from
disclosure under subsection (a-1) of Section 45 of the Day
and Temporary Labor Services Act.
(kk) Information prohibited from disclosure under the
Seizure and Forfeiture Reporting Act.
(ll) Information the disclosure of which is restricted
and exempted under Section 5-30.8 of the Illinois Public
Aid Code.
(mm) Records that are exempt from disclosure under
Section 4.2 of the Crime Victims Compensation Act.
(nn) Information that is exempt from disclosure under
Section 70 of the Higher Education Student Assistance Act.
(oo) Communications, notes, records, and reports
arising out of a peer support counseling session

10400SB3365ham001 - 65 - LRB104 18483 KTG 38682 a
prohibited from disclosure under the First Responders
Suicide Prevention Act.
(pp) Names and all identifying information relating to
an employee of an emergency services provider or law
enforcement agency under the First Responders Suicide
Prevention Act.
(qq) Information and records held by the Department of
Public Health and its authorized representatives collected
under the Reproductive Health Act.
(rr) Information that is exempt from disclosure under
the Cannabis Regulation and Tax Act.
(ss) Data reported by an employer to the Department of
Human Rights pursuant to Section 2-108 of the Illinois
Human Rights Act.
(tt) Recordings made under the Children's Advocacy
Center Act, except to the extent authorized under that
Act.
(uu) Information that is exempt from disclosure under
Section 50 of the Sexual Assault Evidence Submission Act.
(vv) Information that is exempt from disclosure under
subsections (f) and (j) of Section 5-36 of the Illinois
Public Aid Code.
(ww) Information that is exempt from disclosure under
Section 16.8 of the State Treasurer Act.
(xx) Information that is exempt from disclosure or
information that shall not be made public under the

10400SB3365ham001 - 66 - LRB104 18483 KTG 38682 a
Illinois Insurance Code.
(yy) Information prohibited from being disclosed under
the Illinois Educational Labor Relations Act.
(zz) Information prohibited from being disclosed under
the Illinois Public Labor Relations Act.
(aaa) Information prohibited from being disclosed
under Section 1-167 of the Illinois Pension Code.
(bbb) Information that is prohibited from disclosure
by the Illinois Police Training Act and the Illinois State
Police Act.
(ccc) Records exempt from disclosure under Section
2605-304 of the Illinois State Police Law of the Civil
Administrative Code of Illinois.
(ddd) Information prohibited from being disclosed
under Section 35 of the Address Confidentiality for
Victims of Domestic Violence, Sexual Assault, Human
Trafficking, or Stalking Act.
(eee) Information prohibited from being disclosed
under subsection (b) of Section 75 of the Domestic
Violence Fatality Review Act.
(fff) Images from cameras under the Expressway Camera
Act and all automated license plate reader (ALPR)
information used and collected by the Illinois State
Police. "ALPR information" means information gathered by
an ALPR or created from the analysis of data generated by
an ALPR. This subsection (fff) is inoperative on and after

10400SB3365ham001 - 67 - LRB104 18483 KTG 38682 a
July 1, 2028.
(ggg) Information prohibited from disclosure under
paragraph (3) of subsection (a) of Section 14 of the Nurse
Agency Licensing Act.
(hhh) Information submitted to the Illinois State
Police in an affidavit or application for an assault
weapon endorsement, assault weapon attachment endorsement,
.50 caliber rifle endorsement, or .50 caliber cartridge
endorsement under the Firearm Owners Identification Card
Act.
(iii) Data exempt from disclosure under Section 50 of
the School Safety Drill Act.
(jjj) Information exempt from disclosure under Section
30 of the Insurance Data Security Law.
(kkk) Confidential business information prohibited
from disclosure under Section 45 of the Paint Stewardship
Act.
(lll) Data exempt from disclosure under Section
2-3.196 of the School Code.
(mmm) Information prohibited from being disclosed
under subsection (e) of Section 1-129 of the Illinois
Power Agency Act.
(nnn) Materials received by the Department of Commerce
and Economic Opportunity that are confidential under the
Music and Musicians Tax Credit and Jobs Act.
(ooo) Data or information provided pursuant to Section

10400SB3365ham001 - 68 - LRB104 18483 KTG 38682 a
20 of the Statewide Recycling Needs and Assessment Act.
(ppp) Information that is exempt from disclosure under
Section 28-11 of the Lawful Health Care Activity Act.
(qqq) Information that is exempt from disclosure under
Section 7-101 of the Illinois Human Rights Act.
(rrr) Information prohibited from being disclosed
under Section 4-2 of the Uniform Money Transmission
Modernization Act.
(sss) Information exempt from disclosure under Section
40 of the Student-Athlete Endorsement Rights Act.
(ttt) Audio recordings made under Section 30 of the
Illinois State Police Act, except to the extent authorized
under that Section.
(uuu) Information prohibited from being disclosed
under Section 30-5 of the Digital Assets Regulation Act.
(www) Annual summary financial and utilization data
reports submitted to the Health Facilities and Services
Review Board under Section 13 of the Illinois Health
Facilities Planning Act.
(Source: P.A. 103-8, eff. 6-7-23; 103-34, eff. 6-9-23;
103-142, eff. 1-1-24; 103-372, eff. 1-1-24; 103-472, eff.
8-1-24; 103-508, eff. 8-4-23; 103-580, eff. 12-8-23; 103-592,
eff. 6-7-24; 103-605, eff. 7-1-24; 103-636, eff. 7-1-24;
103-724, eff. 1-1-25; 103-786, eff. 8-7-24; 103-859, eff.
8-9-24; 103-991, eff. 8-9-24; 103-1049, eff. 8-9-24; 103-1081,
eff. 3-21-25; 104-10, eff. 6-16-25; 104-18, eff. 6-30-25;

10400SB3365ham001 - 69 - LRB104 18483 KTG 38682 a
104-417, eff. 8-15-25; 104-428, eff. 8-18-25; 104-457, eff.
6-1-26; revised 1-7-26.)
(Text of Section after amendment by P.A. 104-441)
Sec. 7.5. Statutory exemptions. To the extent provided for
by the statutes referenced below, the following shall be
exempt from inspection and copying:
(a) All information determined to be confidential
under Section 4002 of the Technology Advancement and
Development Act.
(b) Library circulation and order records identifying
library users with specific materials under the Library
Records Confidentiality Act.
(c) Applications, related documents, and medical
records received by the Experimental Organ Transplantation
Procedures Board and any and all documents or other
records prepared by the Experimental Organ Transplantation
Procedures Board or its staff relating to applications it
has received.
(d) Information and records held by the Department of
Public Health and its authorized representatives relating
to known or suspected cases of sexually transmitted
infection or any information the disclosure of which is
restricted under the Illinois Sexually Transmitted
Infection Control Act.
(e) Information the disclosure of which is exempted

10400SB3365ham001 - 70 - LRB104 18483 KTG 38682 a
under Section 30 of the Radon Industry Licensing Act.
(f) Firm performance evaluations under Section 55 of
the Architectural, Engineering, and Land Surveying
Qualifications Based Selection Act.
(g) Information the disclosure of which is restricted
and exempted under Section 50 of the Illinois Prepaid
Tuition Act.
(h) Information the disclosure of which is exempted
under the State Officials and Employees Ethics Act, and
records of any lawfully created State or local inspector
general's office that would be exempt if created or
obtained by an Executive Inspector General's office under
that Act.
(i) Information contained in a local emergency energy
plan submitted to a municipality in accordance with a
local emergency energy plan ordinance that is adopted
under Section 11-21.5-5 of the Illinois Municipal Code.
(j) Information and data concerning the distribution
of surcharge moneys collected and remitted by carriers
under the Emergency Telephone System Act.
(k) Law enforcement officer identification information
or driver identification information compiled by a law
enforcement agency or the Department of Transportation
under Section 11-212 of the Illinois Vehicle Code.
(l) Records and information provided to a residential
health care facility resident sexual assault and death

10400SB3365ham001 - 71 - LRB104 18483 KTG 38682 a
review team or the Executive Council under the Abuse
Prevention Review Team Act.
(m) Information provided to the predatory lending
database created pursuant to Article 3 of the Residential
Real Property Disclosure Act, except to the extent
authorized under that Article.
(n) Defense budgets and petitions for certification of
compensation and expenses for court appointed trial
counsel as provided under Sections 10 and 15 of the
Capital Crimes Litigation Act (repealed). This subsection
(n) shall apply until the conclusion of the trial of the
case, even if the prosecution chooses not to pursue the
death penalty prior to trial or sentencing.
(o) Information that is prohibited from being
disclosed under Section 4 of the Illinois Health and
Hazardous Substances Registry Act.
(p) Security portions of system safety program plans,
investigation reports, surveys, schedules, lists, data, or
information compiled, collected, or prepared by or for the
Department of Transportation under Sections 2705-300 and
2705-616 of the Department of Transportation Law of the
Civil Administrative Code of Illinois, the Northern
Illinois Transit Authority under Section 2.11 of the
Northern Illinois Transit Authority Act, or the St. Clair
County Transit District under the Bi-State Transit Safety
Act (repealed).

10400SB3365ham001 - 72 - LRB104 18483 KTG 38682 a
(q) Information prohibited from being disclosed by the
Personnel Record Review Act.
(r) Information prohibited from being disclosed by the
Illinois School Student Records Act.
(s) Information the disclosure of which is restricted
under Section 5-108 of the Public Utilities Act.
(t) (Blank).
(u) Records and information provided to an independent
team of experts under the Developmental Disability and
Mental Health Safety Act (also known as Brian's Law).
(v) Names and information of people who have applied
for or received Firearm Owner's Identification Cards under
the Firearm Owners Identification Card Act or applied for
or received a concealed carry license under the Firearm
Concealed Carry Act, unless otherwise authorized by the
Firearm Concealed Carry Act; and databases under the
Firearm Concealed Carry Act, records of the Concealed
Carry Licensing Review Board under the Firearm Concealed
Carry Act, and law enforcement agency objections under the
Firearm Concealed Carry Act.
(v-5) Records of the Firearm Owner's Identification
Card Review Board that are exempted from disclosure under
Section 10 of the Firearm Owners Identification Card Act.
(w) Personally identifiable information which is
exempted from disclosure under subsection (g) of Section
19.1 of the Toll Highway Act.

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(x) Information which is exempted from disclosure
under Section 5-1014.3 of the Counties Code or Section
8-11-21 of the Illinois Municipal Code.
(y) Confidential information under the Adult
Protective Services Act and its predecessor enabling
statute, the Elder Abuse and Neglect Act, including
information about the identity and administrative finding
against any caregiver of a verified and substantiated
decision of abuse, neglect, or financial exploitation of
an eligible adult maintained in the Registry established
under Section 7.5 of the Adult Protective Services Act.
(z) Records and information provided to a fatality
review team or the Illinois Fatality Review Team Advisory
Council under Section 15 of the Adult Protective Services
Act.
(aa) Information which is exempted from disclosure
under Section 2.37 of the Wildlife Code.
(bb) Information which is or was prohibited from
disclosure by the Juvenile Court Act of 1987.
(cc) Recordings made under the Law Enforcement
Officer-Worn Body Camera Act, except to the extent
authorized under that Act.
(dd) Information that is prohibited from being
disclosed under Section 45 of the Condominium and Common
Interest Community Ombudsperson Act.
(ee) Information that is exempted from disclosure

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under Section 30.1 of the Pharmacy Practice Act.
(ff) Information that is exempted from disclosure
under the Revised Uniform Unclaimed Property Act.
(gg) Information that is prohibited from being
disclosed under Section 7-603.5 of the Illinois Vehicle
Code.
(hh) Records that are exempt from disclosure under
Section 1A-16.7 of the Election Code.
(ii) Information which is exempted from disclosure
under Section 2505-800 of the Department of Revenue Law of
the Civil Administrative Code of Illinois.
(jj) Information and reports that are required to be
submitted to the Department of Labor by registering day
and temporary labor service agencies but are exempt from
disclosure under subsection (a-1) of Section 45 of the Day
and Temporary Labor Services Act.
(kk) Information prohibited from disclosure under the
Seizure and Forfeiture Reporting Act.
(ll) Information the disclosure of which is restricted
and exempted under Section 5-30.8 of the Illinois Public
Aid Code.
(mm) Records that are exempt from disclosure under
Section 4.2 of the Crime Victims Compensation Act.
(nn) Information that is exempt from disclosure under
Section 70 of the Higher Education Student Assistance Act.
(oo) Communications, notes, records, and reports

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arising out of a peer support counseling session
prohibited from disclosure under the First Responders
Suicide Prevention Act.
(pp) Names and all identifying information relating to
an employee of an emergency services provider or law
enforcement agency under the First Responders Suicide
Prevention Act.
(qq) Information and records held by the Department of
Public Health and its authorized representatives collected
under the Reproductive Health Act.
(rr) Information that is exempt from disclosure under
the Cannabis Regulation and Tax Act.
(ss) Data reported by an employer to the Department of
Human Rights pursuant to Section 2-108 of the Illinois
Human Rights Act.
(tt) Recordings made under the Children's Advocacy
Center Act, except to the extent authorized under that
Act.
(uu) Information that is exempt from disclosure under
Section 50 of the Sexual Assault Evidence Submission Act.
(vv) Information that is exempt from disclosure under
subsections (f) and (j) of Section 5-36 of the Illinois
Public Aid Code.
(ww) Information that is exempt from disclosure under
Section 16.8 of the State Treasurer Act.
(xx) Information that is exempt from disclosure or

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information that shall not be made public under the
Illinois Insurance Code.
(yy) Information prohibited from being disclosed under
the Illinois Educational Labor Relations Act.
(zz) Information prohibited from being disclosed under
the Illinois Public Labor Relations Act.
(aaa) Information prohibited from being disclosed
under Section 1-167 of the Illinois Pension Code.
(bbb) Information that is prohibited from disclosure
by the Illinois Police Training Act and the Illinois State
Police Act.
(ccc) Records exempt from disclosure under Section
2605-304 of the Illinois State Police Law of the Civil
Administrative Code of Illinois.
(ddd) Information prohibited from being disclosed
under Section 35 of the Address Confidentiality for
Victims of Domestic Violence, Sexual Assault, Human
Trafficking, or Stalking Act.
(eee) Information prohibited from being disclosed
under subsection (b) of Section 75 of the Domestic
Violence Fatality Review Act.
(fff) Images from cameras under the Expressway Camera
Act and all automated license plate reader (ALPR)
information used and collected by the Illinois State
Police. "ALPR information" means information gathered by
an ALPR or created from the analysis of data generated by

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an ALPR. This subsection (fff) is inoperative on and after
July 1, 2028.
(ggg) Information prohibited from disclosure under
paragraph (3) of subsection (a) of Section 14 of the Nurse
Agency Licensing Act.
(hhh) Information submitted to the Illinois State
Police in an affidavit or application for an assault
weapon endorsement, assault weapon attachment endorsement,
.50 caliber rifle endorsement, or .50 caliber cartridge
endorsement under the Firearm Owners Identification Card
Act.
(iii) Data exempt from disclosure under Section 50 of
the School Safety Drill Act.
(jjj) Information exempt from disclosure under Section
30 of the Insurance Data Security Law.
(kkk) Confidential business information prohibited
from disclosure under Section 45 of the Paint Stewardship
Act.
(lll) Data exempt from disclosure under Section
2-3.196 of the School Code.
(mmm) Information prohibited from being disclosed
under subsection (e) of Section 1-129 of the Illinois
Power Agency Act.
(nnn) Materials received by the Department of Commerce
and Economic Opportunity that are confidential under the
Music and Musicians Tax Credit and Jobs Act.

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(ooo) Data or information provided pursuant to Section
20 of the Statewide Recycling Needs and Assessment Act.
(ppp) Information that is exempt from disclosure under
Section 28-11 of the Lawful Health Care Activity Act.
(qqq) Information that is exempt from disclosure under
Section 7-101 of the Illinois Human Rights Act.
(rrr) Information prohibited from being disclosed
under Section 4-2 of the Uniform Money Transmission
Modernization Act.
(sss) Information exempt from disclosure under Section
40 of the Student-Athlete Endorsement Rights Act.
(ttt) Audio recordings made under Section 30 of the
Illinois State Police Act, except to the extent authorized
under that Section.
(uuu) Information prohibited from being disclosed
under Section 30-5 of the Digital Assets Regulation Act.
(vvv) (uuu) Information exempt from disclosure under
Section 70 of the End-of-Life Options for Terminally Ill
Patients Act.
(www) Annual summary financial and utilization data
reports submitted to the Health Facilities and Services
Review Board under Section 13 of the Illinois Health
Facilities Planning Act.
(Source: P.A. 103-8, eff. 6-7-23; 103-34, eff. 6-9-23;
103-142, eff. 1-1-24; 103-372, eff. 1-1-24; 103-472, eff.
8-1-24; 103-508, eff. 8-4-23; 103-580, eff. 12-8-23; 103-592,

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eff. 6-7-24; 103-605, eff. 7-1-24; 103-636, eff. 7-1-24;
103-724, eff. 1-1-25; 103-786, eff. 8-7-24; 103-859, eff.
8-9-24; 103-991, eff. 8-9-24; 103-1049, eff. 8-9-24; 103-1081,
eff. 3-21-25; 104-10, eff. 6-16-25; 104-18, eff. 6-30-25;
104-417, eff. 8-15-25; 104-428, eff. 8-18-25; 104-441, eff.
9-12-26; 104-457, eff. 6-1-26; revised 1-7-26.)
Section 6-75. The Illinois Health Facilities Planning Act
is amended by changing Sections 2 and 13 as follows:
(20 ILCS 3960/2) (from Ch. 111 1/2, par. 1152)
(Section scheduled to be repealed on December 31, 2029)
Sec. 2. Purpose of the Act. This Act shall establish a
procedure (1) which requires a person establishing,
constructing or modifying a health care facility, as herein
defined, to have the qualifications, background, character and
financial resources to adequately provide a proper service for
the community; (2) that promotes the orderly and economic
development of health care facilities in the State of Illinois
that avoids unnecessary duplication of such facilities; and
(3) that promotes planning for and development of health care
facilities needed for comprehensive health care especially in
areas where the health planning process has identified unmet
needs.
The changes made to this Act by this amendatory Act of the
96th General Assembly are intended to accomplish the following

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objectives: to improve the financial ability of the public to
obtain necessary health services; to establish an orderly and
comprehensive health care delivery system that will guarantee
the availability of quality health care to the general public;
to maintain and improve the provision of essential health care
services and increase the accessibility of those services to
the medically underserved and indigent; to assure that the
reduction and closure of health care services or facilities is
performed in an orderly and timely manner, and that these
actions are deemed to be in the best interests of the public;
and to assess the financial burden to patients caused by
unnecessary health care construction and modification.
Evidence-based assessments, projections and decisions will be
applied regarding capacity, quality, value and equity in the
delivery of health care services in Illinois. The integrity of
the Certificate of Need process is ensured through revised
ethics and communications procedures. Cost containment and
support for safety net services must continue to be central
tenets of the Certificate of Need process.
The changes made to this Act by this amendatory Act of the
104th General Assembly are intended to allow the State to
collect additional information regarding the financial ability
for health care facilities to deliver services in Illinois.
(Source: P.A. 99-527, eff. 1-1-17.)
(20 ILCS 3960/13) (from Ch. 111 1/2, par. 1163)

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(Section scheduled to be repealed on December 31, 2029)
Sec. 13. Investigation of applications for permits.
(a) Investigations. The State Board shall make or cause to
be made such investigations as it deems necessary in
connection with an application for a permit, or in connection
with a determination of whether or not construction or
modification that has been commenced is in accord with the
permit issued by the State Board, or whether construction or
modification has been commenced without a permit having been
obtained. The State Board may issue subpoenas duces tecum
requiring the production of records and may administer oaths
to such witnesses.
Any circuit court of this State, upon the application of
the State Board or upon the application of any party to such
proceedings, may, in its discretion, compel the attendance of
witnesses, the production of books, papers, records, or
memoranda and the giving of testimony before the State Board,
by a proceeding as for contempt, or otherwise, in the same
manner as production of evidence may be compelled before the
court.
(b) Reports from health facilities. The State Board shall
require all health facilities operating in this State to
provide such reasonable reports at such times and containing
such information as is needed by it to carry out the purposes
and provisions of this Act. Prior to collecting information
from health facilities, the State Board shall make reasonable

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efforts through a public process to consult with health
facilities and associations that represent them to determine
whether data and information requests will result in useful
information for health planning, whether sufficient
information is available from other sources, and whether data
requested is routinely collected by health facilities and is
available without retrospective record review. Data and
information requests shall not impose undue paperwork burdens
on health care facilities and personnel. Health facilities not
complying with this requirement shall be reported to
licensing, accrediting, certifying, or payment agencies as
being in violation of State law. Health care facilities and
other parties at interest shall have reasonable access, under
rules established by the State Board, to all planning
information submitted in accord with this Act pertaining to
their area.
(1) Questionnaires. Among the reports to be required
by the State Board are facility questionnaires for health
care facilities licensed under the Ambulatory Surgical
Treatment Center Act, the Hospital Licensing Act, the
Nursing Home Care Act, the ID/DD Community Care Act, the
MC/DD Act, or the Specialized Mental Health Rehabilitation
Act of 2013 and health care facilities that are required
to meet the requirements of 42 CFR 494 in order to be
certified for participation in Medicare and Medicaid under
Titles XVIII and XIX of the federal Social Security Act.

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These questionnaires shall be conducted on an annual basis
and compiled by the State Board. For health care
facilities licensed under the Nursing Home Care Act or the
Specialized Mental Health Rehabilitation Act of 2013,
these reports shall include, but not be limited to, the
identification of specialty services provided by the
facility to patients, residents, and the community at
large. Annual reports for facilities licensed under the
ID/DD Community Care Act and facilities licensed under the
MC/DD Act shall be different from the annual reports
required of other health care facilities and shall be
specific to those facilities licensed under the ID/DD
Community Care Act or the MC/DD Act. The Health Facilities
and Services Review Board shall consult with associations
representing facilities licensed under the ID/DD Community
Care Act and associations representing facilities licensed
under the MC/DD Act when developing the information
requested in these annual reports. For health care
facilities that contain long term care beds, the reports
shall also include the number of staffed long term care
beds, physical capacity for long term care beds at the
facility, and long term care beds available for immediate
occupancy. For purposes of this paragraph, "long term care
beds" means beds (i) licensed under the Nursing Home Care
Act, (ii) licensed under the ID/DD Community Care Act,
(iii) licensed under the MC/DD Act, (iv) licensed under

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the Hospital Licensing Act, or (v) licensed under the
Specialized Mental Health Rehabilitation Act of 2013 and
certified as skilled nursing or nursing facility beds
under Medicaid or Medicare.
For health care facilities licensed under the Hospital
Licensing Act, the health care facilities operating in
this State shall report the following financial and
utilization data annually: (i) the most recent audited
financial statements; (ii) the most recent month-end
balance sheet detailing the assets, liabilities, and net
worth at the end of the month immediately preceding the
annual reporting cycle; (iii) the most recent income
statement for the month immediately preceding the annual
reporting cycle summarizing the revenues, expenses, and
net income; (iv) the total number of inpatient days,
outpatient visits, and discharges by payer, including, but
not limited to, Medicare, Medicaid fee-for-service,
Medicaid managed care, commercial coverage, and other
payers; (v) the total inpatient gross revenues by payer,
including, but not limited to, Medicare, Medicaid
fee-for-service, Medicaid managed care, commercial
coverage, and other payers; and (vi) the total outpatient
gross revenues by payer, including, but not limited to,
Medicare, Medicaid fee-for-service, Medicaid managed care,
commercial coverage, and other payers. The transmission of
the financial and utilization data shall be due to the

10400SB3365ham001 - 85 - LRB104 18483 KTG 38682 a
State Board within 90 days after the effective date of
this amendatory Act of the 104th General Assembly, and
thereafter, the data shall be due annually on the regular
schedule set by the State Board for questionnaires. The
State Board, in coordination with the Department of
Healthcare and Family Services and the Department of
Public Health, shall administer the collection of the
financial and utilization data submitted under this
Section. The State Board may adopt any administrative
rules, including emergency rules, necessary to implement
this Section, including requesting additional information
or removing information from the reporting requirements.
If a health care facility has not filed the required
financial and utilization data within 90 days after the
close of the annual reporting period, the State Board
shall impose fines of not more than $5,000 per week for
failure to comply with the provisions of this Section.
(2) Confidentiality.
(A) The State Board shall keep confidential the
annual summary financial and utilization data report
submitted under this Section and all information in
the report as required by this Section. The financial
and utilization data shall remain confidential, is not
subject to subpoena, is not subject to discovery or
admissible as evidence in private civil litigation, is
not subject to disclosure under the Freedom of

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Information Act, and must not be made public at any
time or used by the State Board or any other person,
except as provided in subparagraphs (B), (D), and (E)
of this paragraph (2).
(B) Notwithstanding subparagraph (A), the State
Board may:
(i) share the financial and utilization data
submitted under this Section with other State
agencies;
(ii) share the financial and utilization data
submitted under this Section with third-party
vendors or contractors of a State agency, federal
regulatory agencies, or law enforcement
authorities, if the recipient agrees to and
verifies in writing its legal authority to
maintain the confidentiality and privileged status
of the financial and utilization data;
(iii) enter into agreements governing the
sharing and use of information consistent with
this Section.
(C) Disclosure of the financial and utilization
data to the State Board and by the State Board under
this Section does not waive any applicable privilege
or claim of confidentiality in the report or
information.
(D) Notwithstanding the confidentiality

10400SB3365ham001 - 87 - LRB104 18483 KTG 38682 a
requirements of this Section or otherwise imposed by
State law, relevant State agencies may make public
financial and utilization data submitted under this
Section in an aggregated format that does not disclose
information or data attributed to any specific
facility.
(E) Notwithstanding the confidentiality
requirements of this Section, a State agency may
disclose the financial and utilization data submitted
under this Section with the written consent of the
hospital that submitted the report.
(Source: P.A. 100-681, eff. 8-3-18; 100-957, eff. 8-19-18;
101-81, eff. 7-12-19.)
Section 6-80. The Hospital Licensing Act is amended by
adding Section 4.8 as follows:
(210 ILCS 85/4.8 new)
Sec. 4.8. Additional licensing requirements.
(a) Hospital emergency and financial contingency plan. Any
hospital licensed under this Act that has outstanding debts to
the State in the form of tax arrears or that maintains debt
through the Distressed Hospital Loan Program or other Medicaid
advance payments shall submit to the Department a hospital
emergency and financial contingency plan for the rapid and
orderly resolution of finances and operations in the event of

10400SB3365ham001 - 88 - LRB104 18483 KTG 38682 a
material financial distress. The plan shall be submitted on an
annual basis until any outstanding assessment or advance
balances have been fully paid. The plan shall include, but not
be limited to, procedures for the safe and orderly transfer
and continuity of care for patients if closure of at least one
category of service, or a temporary suspension of such service
for any reason, were to occur. Potential events precipitating
closure or suspended services that shall be addressed in the
plan, include, but are not limited to: financial distress,
regulatory and compliance issues, operational or workforce
challenges, infrastructure and facility issues, emergency or
disaster related causes, and strategic organizational
decisions. The plan shall contemplate (i) the identification
of potential service area gaps created due to emergency
closure and suspension of services and (ii) the orderly
preservation and transfer of medical records in accordance
with the Medical Patient Rights Act, the Health Insurance
Portability and Accountability Act of 1996, and other
applicable medical privacy laws.
(b) Hospital emergency and financial contingency plans for
hospitals with multiple locations operating under a single
license. Any hospital licensed by the Department under Section
4.5 of this Act and required to submit a hospital emergency and
financial contingency plan shall submit a hospital emergency
and financial contingency plan as outlined in subsection (a)
considering each location, campus, or facility administered

10400SB3365ham001 - 89 - LRB104 18483 KTG 38682 a
under the license that could reasonably be affected.
(c) Annual filing. Hospital emergency and financial
contingency plans shall be filed with the Department no later
than 3 months after the effective date of this amendatory Act
of the 104th General Assembly. Hospital emergency and
financial contingency plans, or annual affirmations of
previously filed hospital emergency and financial contingency
plans, as outlined in this Section shall be submitted on an
annual basis as determined by the Department through
administrative rule.
(d) Penalties for noncompliance. The Department may impose
fines of not more than $500 per week for failure to comply with
the provisions of this Section.
(e) This Section is operative on and after January 1,
2027.
ARTICLE 10.
Section 10-5. The Rebuild Illinois Mental Health Workforce
Act is amended by changing Section 20-10 as follows:
(305 ILCS 66/20-10)
Sec. 20-10. Medicaid funding for community mental health
services. Medicaid funding for the specific community mental
health services listed in this Act shall be adjusted and paid
as set forth in this Act. Such payments shall be paid in

10400SB3365ham001 - 90 - LRB104 18483 KTG 38682 a
addition to the base Medicaid reimbursement rate and add-on
payment rates per service unit.
(a) The following payment adjustments shall begin on July
1, 2022 for State Fiscal Year 2023 and shall continue for every
State fiscal year thereafter.
(1) Individual Therapy Medicaid Payment rate for
services provided under the H0004 Code:
(A) The Medicaid total payment rate for individual
therapy provided by a qualified mental health
professional shall be increased by no less than $9 per
service unit.
(B) The Medicaid total payment rate for individual
therapy provided by a mental health professional shall
be increased by no less than $9 per service unit.
(2) Community Support - Individual Medicaid Payment
rate for services provided under the H2015 Code: All
community support - individual services shall be increased
by no less than $15 per service unit.
(3) Case Management Medicaid Add-on Payment for
services provided under the T1016 code: All case
management services rates shall be increased by no less
than $15 per service unit.
(4) Assertive Community Treatment Medicaid Add-on
Payment for services provided under the H0039 code: The
Medicaid total payment rate for assertive community
treatment services shall increase by no less than $8 per

10400SB3365ham001 - 91 - LRB104 18483 KTG 38682 a
service unit.
(b) (5) Medicaid user-based directed payments. The
following directed payments shall be paid to qualifying
providers for State Fiscal Year 2023 through State Fiscal Year
2026. This subsection does not prevent the Department from
making payments in future State fiscal years to correct errors
or omissions made in State Fiscal Year 2023 through State
Fiscal Year 2026 payments.
(1) (A) For each State fiscal year, a monthly directed
payment shall be paid to a community mental health
provider of community support team services based on the
number of Medicaid users of community support team
services documented by Medicaid fee-for-service and
managed care encounter claims delivered by that provider
in the base year. The Department of Healthcare and Family
Services shall make the monthly directed payment to each
provider entitled to directed payments under this Act by
no later than the last day of each month throughout each
State fiscal year.
(A) (i) The monthly directed payment for a
community support team provider shall be calculated as
follows: The sum total number of individual Medicaid
users of community support team services delivered by
that provider throughout the base year, multiplied by
$4,200 per Medicaid user, divided into 12 equal
monthly payments for the State fiscal year.

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(B) (ii) As used in this subparagraph, "user"
means an individual who received at least 200 units of
community support team services (H2016) during the
base year.
(2) (B) For each State fiscal year, a monthly directed
payment shall be paid to each community mental health
provider of assertive community treatment services based
on the number of Medicaid users of assertive community
treatment services documented by Medicaid fee-for-service
and managed care encounter claims delivered by the
provider in the base year.
(A) (i) The monthly direct payment for an
assertive community treatment provider shall be
calculated as follows: The sum total number of
Medicaid users of assertive community treatment
services provided by that provider throughout the base
year, multiplied by $6,000 per Medicaid user, divided
into 12 equal monthly payments for that State fiscal
year.
(B) (ii) As used in this subparagraph, "user"
means an individual that received at least 300 units
of assertive community treatment services during the
base year.
(3) (C) The base year for directed payments under this
Section shall be calendar year 2019 for State Fiscal Year
2023 and State Fiscal Year 2024. For the State fiscal year

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beginning on July 1, 2024, and for every State fiscal year
thereafter, the base year shall be the calendar year that
ended 18 months prior to the start of the State fiscal year
in which payments are made.
(b-5) (b) Subject to federal approval, a one-time directed
payment must be made in calendar year 2023 for community
mental health services provided by community mental health
providers. The one-time directed payment shall be for an
amount appropriated for these purposes. The one-time directed
payment shall be for services for Integrated Assessment and
Treatment Planning and other intensive services, including,
but not limited to, services for Mobile Crisis Response,
crisis intervention, and medication monitoring. The amounts
and services used for designing and distributing these
one-time directed payments shall not be construed to require
any future rate or funding increases for the same or other
mental health services.
(b-6) Subject to federal approval, for dates of service on
and after July 1, 2026, the Medicaid reimbursement rates for
Assertive Community Treatment and Community Support Team
services shall be increased by an amount no less than the
following targeted pools. The Department must use service
units delivered under the fee-for-service and managed care
programs by community mental health centers during State
Fiscal Year 2024 for distributing the targeted pools and
setting rates.

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(1) Assertive Community Treatment, $10,600,000; and
(2) Community Support Team services, $17,500,000.
(c) The following payment adjustments shall be made:
(1) Subject to federal approval, beginning on January
1, 2024, the Department shall introduce rate increases to
behavioral health services no less than by the following
targeted pool for the specified services provided by
community mental health centers:
(A) Mobile Crisis Response, $6,800,000;
(B) Crisis Intervention, $4,000,000;
(C) Integrative Assessment and Treatment Planning
services, $10,500,000;
(D) Group Therapy, $1,200,000;
(E) Family Therapy, $500,000;
(F) Community Support Group, $4,000,000; and
(G) Medication Monitoring, $3,000,000.
(2) Rate increases shall be determined with
significant input from Illinois behavioral health trade
associations and advocates. The Department must use
service units delivered under the fee-for-service and
managed care programs by community mental health centers
during State Fiscal Year 2022. These services are used for
distributing the targeted pools and setting rates but do
not prohibit the Department from paying providers not
enrolled as community mental health centers the same rate
if providing the same services.

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(d) Rate simplification for team-based services.
(1) The Department shall work with stakeholders to
redesign reimbursement rates for behavioral health
team-based services established under the Rehabilitation
Option of the Illinois Medicaid State Plan supporting
individuals with chronic or complex behavioral health
conditions and crisis services. Subject to federal
approval, the redesigned rates shall seek to introduce
bundled payment systems that minimize provider claiming
activities while transitioning the focus of treatment
towards metrics and outcomes. Federally approved rate
models shall seek to ensure reimbursement levels are no
less than the State's total reimbursement for similar
services in calendar year 2023, including all service
level payments, add-ons, and all other payments specified
in this Section.
(2) In State Fiscal Year 2024, the Department shall
identify an existing, or establish a new, Behavioral
Health Outcomes Stakeholder Workgroup to help inform the
identification of metrics and outcomes for team-based
services.
(3) In State Fiscal Year 2025, subject to federal
approval, the Department shall introduce a
pay-for-performance model for team-based services to be
informed by the Behavioral Health Outcomes Stakeholder
Workgroup.

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(Source: P.A. 102-699, eff. 4-19-22; 102-1118, eff. 1-18-23;
103-102, eff. 7-1-23; 103-154, eff. 6-30-23.)
ARTICLE 15.
Section 15-5. The State Finance Act is amended by changing
Section 5.945 as follows:
(30 ILCS 105/5.945)
Sec. 5.945. The Medicaid Technical Assistance Center Fund.
Notwithstanding any other provision of law, in addition to any
other transfers that may be provided by law, on July 1, 2026,
or as soon thereafter as practical, the State Comptroller
shall direct and the State Treasurer shall transfer the
remaining balance from the Medicaid Technical Assistance
Center Fund into the Healthcare Provider Relief Fund. Upon
completion of the transfers, the Medicaid Technical Assistance
Center Fund is dissolved, and any future deposits due to that
Fund and any outstanding obligations or liabilities of that
Fund pass to the Healthcare Provider Relief Fund.
(Source: P.A. 102-4, Article 185, Section 185-90, eff.
4-27-21; 102-813, eff. 5-13-22.)
Section 15-10. The Medicaid Technical Assistance Act is
amended by changing Sections 185-5 and 185-15 as follows:

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(305 ILCS 75/185-5)
Sec. 185-5. Definitions. As used in this Act:
"Behavioral health providers" includes providers of mental
health, substance use disorder, developmental disabilities,
and autism services for purposes of this Act, but does not
change any other legal, programmatic, diagnostic, or clinical
provisions defining or relating to coverage of such services.
means mental health and substance use disorder providers.
"Department" means the Department of Healthcare and Family
Services.
"Health care providers" means individuals and
organizations that who provide physical, mental, or substance
use disorder services, or services supporting social
determinants determinant of health services.
"Health equity" means providing care that does not vary in
quality because of personal characteristics such as gender,
ethnicity, geographic location, and socioeconomic status.
"Network adequacy" means a Medicaid beneficiaries' ability
to access all necessary provider types within time and
distance standards as defined in the Managed Care Organization
model contract.
"Service deserts" means geographic areas of the State with
no or limited Medicaid providers that accept Medicaid.
"Social determinants of health" means any conditions that
impact an individual's health, including, but not limited to,
access to healthy food, safety, education, and housing

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stability.
"Stakeholders" means, but are not limited to, health care
providers, advocacy organizations, managed care organizations,
Medicaid beneficiaries, and State and city partners.
(Source: P.A. 102-4, eff. 4-27-21.)
(305 ILCS 75/185-15)
Sec. 185-15. Collaboration. The Medicaid Technical
Assistance Center shall collaborate with public and private
partners throughout the State to identify, establish, and
maintain best practices necessary for health providers to
ensure their capacity to participate in the Illinois Medical
Assistance Program. The Medicaid Technical Assistance Center
shall promote equitable delivery systems, remaining committed
to the principle that all Medicaid recipients have accessible
and equitable physical and mental health care services
HealthChoice Illinois or YouthCare. The Medicaid Technical
Assistance Center shall administer the following:
(1) Outreach and engagement: The Medicaid Technical
Assistance Center shall undertake efforts to identify and
engage community-based providers offering services to
customers funded by the Department, including, but not
limited to, behavioral health services and or services
addressing the social determinants of health, especially
those predominantly serving communities of color or those
operating within or near service deserts, for the purpose

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of offering training and technical assistance to them
through the Medicaid Technical Assistance Center. Outreach
and engagement services may be subcontracted.
(2) Trainings: The Medicaid Technical Assistance
Center shall create and administer ongoing trainings for
health care providers. Trainings may be subcontracted. The
Medicaid Technical Assistance Center shall provide
in-person and web-based trainings. In-person training
shall be conducted throughout the State. All trainings
must be free of charge. The Medicaid Technical Assistance
Center shall administer post-training surveys and
incorporate feedback. Training content and delivery must
be reflective of Illinois providers' varying levels of
readiness, resources, and client populations.
(3) Web-based resources: The Medicaid Technical
Assistance Center shall maintain an independent, easy to
navigate, and up-to-date website that includes, but is not
limited to: recorded training archives, a training
calendar, provider resources and tools, up-to-date
explanations of Department and managed care organization
guidance, a running database of frequently asked questions
and contact information for key staff members of the
Department, managed care organizations, and the Medicaid
Technical Assistance Center.
(4) Learning collaboratives: The Medicaid Technical
Assistance Center shall host regional learning

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collaboratives that will supplement the Medicaid Technical
Assistance Center training curriculum to bring together
groups of stakeholders to share issues and best practices,
and to escalate issues. Leadership of the Department and
managed care organizations shall attend learning
collaboratives on a quarterly basis.
(5) Network recruitment plan: Using reports and data
provided by the Department's External Quality Review
Organization on adequacy reports: The Medicaid Technical
Assistance Center shall publicly release a report on
Medicaid provider network adequacy, within the first 3
years of implementation and annually thereafter. The
reports shall identify provider service deserts, and
health care disparities by race and ethnicity, the
Medicaid Technical Assistance Center shall propose for
Department review and approval an annual plan for
recruiting providers to participate in the Illinois
Medical Assistance Program and report on outcomes of its
recruitment efforts to the Department for continuous
improvement. Recruitment plans shall prioritize efforts to
bolster access in provider service deserts and in
communities experiencing health care disparities by race
and ethnicity, with a special focus on behavioral health
services and services that address social determinants of
health.
(6) Equitable delivery system: The Medicaid Technical

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Assistance Center is committed to the principle that all
Medicaid recipients have accessible and equitable physical
and mental health care services. All providers served
through the Medicaid Technical Assistance Center shall
deliver services notwithstanding the patient's race,
color, gender, gender identity, age, ancestry, marital
status, military status, religion, national origin,
disability status, sexual orientation, order of protection
status, as defined under Section 1-103 of the Illinois
Human Rights Act, or immigration status.
(Source: P.A. 102-4, eff. 4-27-21.)
(305 ILCS 75/185-20 rep.)
(305 ILCS 75/185-25 rep.)
Section 15-15. The Medicaid Technical Assistance Act is
amended by repealing Sections 185-20 and 185-25.
ARTICLE 20.
Section 20-5. The Illinois Public Aid Code is amended by
changing Section 5-5f as follows:
(305 ILCS 5/5-5f)
Sec. 5-5f. Elimination and limitations of medical
assistance services. Notwithstanding any other provision of
this Code to the contrary, on and after July 1, 2012:

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(a) The following service shall no longer be a covered
service available under this Code: group psychotherapy for
residents of any facility licensed under the Nursing Home
Care Act or the Specialized Mental Health Rehabilitation
Act of 2013.
(b) The Department shall place the following
limitations on services: (i) the Department shall limit
adult eyeglasses to one pair every 2 years; however, the
limitation does not apply to an individual who needs
different eyeglasses following a surgical procedure such
as cataract surgery; (ii) the Department shall set an
annual limit of a maximum of 20 visits for each of the
following services: adult speech, hearing, and language
therapy services, adult occupational therapy services, and
physical therapy services; on or after October 1, 2014,
the annual maximum limit of 20 visits shall expire but the
Department may require prior approval for all individuals
for speech, hearing, and language therapy services,
occupational therapy services, and physical therapy
services; (iii) the Department shall limit adult podiatry
services to individuals with diabetes; on or after October
1, 2014, podiatry services shall not be limited to
individuals with diabetes; (iv) the Department shall pay
for caesarean sections at the normal vaginal delivery rate
unless a caesarean section was medically necessary; (v)
the Department shall limit adult dental services to

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emergencies; beginning July 1, 2013, the Department shall
ensure that the following conditions are recognized as
emergencies: (A) dental services necessary for an
individual in order for the individual to be cleared for a
medical procedure, such as a transplant; (B) extractions
and dentures necessary for a diabetic to receive proper
nutrition; (C) extractions and dentures necessary as a
result of cancer treatment; and (D) dental services
necessary for the health of a pregnant woman prior to
delivery of her baby; on or after July 1, 2014, adult
dental services shall no longer be limited to emergencies,
and dental services necessary for the health of a pregnant
woman prior to delivery of her baby shall continue to be
covered; and (vi) effective July 1, 2012 through June 30,
2021, the Department shall place limitations and require
concurrent review on every inpatient detoxification stay
to prevent repeat admissions to any hospital for
detoxification within 60 days of a previous inpatient
detoxification stay. The Department shall convene a
workgroup of hospitals, substance abuse providers, care
coordination entities, managed care plans, and other
stakeholders to develop recommendations for quality
standards, diversion to other settings, and admission
criteria for patients who need inpatient detoxification,
which shall be published on the Department's website no
later than September 1, 2013.

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(c) The Department shall require prior approval of the
following services: wheelchair repairs costing more than
$750, coronary artery bypass graft, and bariatric surgery
consistent with Medicare standards concerning patient
responsibility. Wheelchair repair prior approval requests
shall be adjudicated within one business day of receipt of
complete supporting documentation. Providers may not break
wheelchair repairs into separate claims for purposes of
staying under the $750 threshold for requiring prior
approval. The wholesale price of manual and power
wheelchairs, durable medical equipment and supplies, and
complex rehabilitation technology products and services
shall be defined as actual acquisition cost including all
discounts.
(d) (Blank). The Department shall establish benchmarks
for hospitals to measure and align payments to reduce
potentially preventable hospital readmissions, inpatient
complications, and unnecessary emergency room visits. In
doing so, the Department shall consider items, including,
but not limited to, historic and current acuity of care
and historic and current trends in readmission. The
Department shall publish provider-specific historical
readmission data and anticipated potentially preventable
targets 60 days prior to the start of the program. In the
instance of readmissions, the Department shall adopt
policies and rates of reimbursement for services and other

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payments provided under this Code to ensure that, by June
30, 2013, expenditures to hospitals are reduced by, at a
minimum, $40,000,000.
(e) The Department shall establish utilization
controls for the hospice program such that it shall not
pay for other care services when an individual is in
hospice.
(f) For home health services, the Department shall
require Medicare certification of providers participating
in the program and implement the Medicare face-to-face
encounter rule. The Department shall require providers to
implement auditable electronic service verification based
on global positioning systems or other cost-effective
technology.
(g) For the Home Services Program operated by the
Department of Human Services and the Community Care
Program operated by the Department on Aging, the
Department of Human Services, in cooperation with the
Department on Aging, shall implement an electronic service
verification based on global positioning systems or other
cost-effective technology.
(h) Effective with inpatient hospital admissions on or
after July 1, 2012, the Department shall reduce the
payment for a claim that indicates the occurrence of a
provider-preventable condition during the admission as
specified by the Department in rules. The Department shall

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not pay for services related to an other
provider-preventable condition.
As used in this subsection (h):
"Provider-preventable condition" means a health care
acquired condition as defined under the federal Medicaid
regulation found at 42 CFR 447.26 or an other
provider-preventable condition.
"Other provider-preventable condition" means a wrong
surgical or other invasive procedure performed on a
patient, a surgical or other invasive procedure performed
on the wrong body part, or a surgical procedure or other
invasive procedure performed on the wrong patient.
(i) The Department shall implement cost savings
initiatives for advanced imaging services, cardiac imaging
services, pain management services, and back surgery. Such
initiatives shall be designed to achieve annual costs
savings.
(j) The Department shall ensure that beneficiaries
with a diagnosis of epilepsy or seizure disorder in
Department records will not require prior approval for
anticonvulsants.
(Source: P.A. 101-209, eff. 8-5-19; 102-43, Article 5, Section
5-5, eff. 7-6-21; 102-43, Article 30, Section 30-5, eff.
7-6-21; 102-43, Article 80, Section 80-5, eff. 7-6-21;
102-813, eff. 5-13-22.)

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ARTICLE 25.
Section 25-5. The Illinois Public Aid Code is amended by
changing Section 14-12 as follows:
(305 ILCS 5/14-12)
Sec. 14-12. Hospital rate reform payment system. The
hospital payment system pursuant to Section 14-11 of this
Article shall be as follows:
(a) Inpatient hospital services. Effective on and after
the effective date of this amendatory Act of the 104th General
Assembly, reimbursement for inpatient general acute care
services shall utilize the All Patient Refined Diagnosis
Related Grouping (APR-DRG) software distributed by SolventumTM
previously known as 3MTM Health Information System. SolventumTM
shall be the exclusive provider of this software unless the
Department determines that SolventumTM is unable to meet the
required operational or contractual terms. Only under these
circumstances may an alternative authorized provider of the
software be considered.
(1) The Department shall establish Medicaid weighting
factors to be used in the reimbursement system established
under this subsection. Initial weighting factors shall be
the weighting factors as published by the authorized
provider of this software adjusted for the Illinois
experience.

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(2) The Department shall establish a
statewide-standardized amount to be used in the inpatient
reimbursement system. The Department shall publish these
amounts on its website no later than 10 calendar days
prior to their effective date.
(3) In addition to the statewide-standardized amount,
the Department shall develop adjusters to adjust the rate
of reimbursement for critical Medicaid providers or
services for trauma, transplantation services, perinatal
care, and Graduate Medical Education (GME).
(4) The Department shall develop add-on payments to
account for exceptionally costly inpatient stays,
consistent with Medicare outlier principles. Outlier fixed
loss thresholds may be updated to control for excessive
growth in outlier payments no more frequently than on an
annual basis, but at least once every 4 years. Upon
updating the fixed loss thresholds, the Department shall
be required to update base rates within 12 months.
(5) The Department shall define those hospitals or
distinct parts of hospitals that shall be exempt from the
APR-DRG reimbursement system established under this
Section. The Department shall publish these hospitals'
inpatient rates on its website no later than 10 calendar
days prior to their effective date.
(6) Beginning July 1, 2014 and ending on December 31,
2023, in addition to the statewide-standardized amount,

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the Department shall develop an adjustor to adjust the
rate of reimbursement for safety-net hospitals defined in
Section 5-5e.1 of this Code excluding pediatric hospitals.
(7) Beginning July 1, 2014, in addition to the
statewide-standardized amount, the Department shall
develop an adjustor to adjust the rate of reimbursement
for Illinois freestanding inpatient psychiatric hospitals
that are not designated as children's hospitals by the
Department but are primarily treating patients under the
age of 21.
(7.5) (Blank).
(8) Beginning July 1, 2018, in addition to the
statewide-standardized amount, the Department shall adjust
the rate of reimbursement for hospitals designated by the
Department of Public Health as a Perinatal Level II or II+
center by applying the same adjustor that is applied to
Perinatal and Obstetrical care cases for Perinatal Level
III centers, as of December 31, 2017.
(9) Beginning July 1, 2018, in addition to the
statewide-standardized amount, the Department shall apply
the same adjustor that is applied to trauma cases as of
December 31, 2017 to inpatient claims to treat patients
with burns, including, but not limited to, APR-DRGs 841,
842, 843, and 844.
(10) Beginning July 1, 2018, the
statewide-standardized amount for inpatient general acute

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care services shall be uniformly increased so that base
claims projected reimbursement is increased by an amount
equal to the funds allocated in paragraph (1) of
subsection (b) of Section 5A-12.6, less the amount
allocated under paragraphs (8) and (9) of this subsection
and paragraphs (3) and (4) of subsection (b) multiplied by
40%.
(11) Beginning July 1, 2018, the reimbursement for
inpatient rehabilitation services shall be increased by
the addition of a $96 per day add-on.
(b) Outpatient hospital services. Effective on and after
the effective date of this amendatory Act of the 104th General
Assembly, reimbursement for outpatient services shall utilize
the Enhanced Ambulatory Procedure Grouping (EAPG) software
distributed by SolventumTM previously known as 3MTM Health
Information System. SolventumTM shall be the exclusive
provider of this software unless the Agency determines that
SolventumTM is unable to meet the required operational or
contractual terms. Only under these circumstances may an
alternative authorized provider of the software be considered.
(1) The Department shall establish Medicaid weighting
factors to be used in the reimbursement system established
under this subsection. The initial weighting factors shall
be the weighting factors as published by the authorized
provider.
(2) The Department shall establish service specific

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statewide-standardized amounts to be used in the
reimbursement system.
(A) The initial statewide standardized amounts,
with the labor portion adjusted by the Calendar Year
2013 Medicare Outpatient Prospective Payment System
wage index with reclassifications, shall be published
by the Department on its website no later than 10
calendar days prior to their effective date.
(B) The Department shall establish adjustments to
the statewide-standardized amounts for each Critical
Access Hospital, as designated by the Department of
Public Health in accordance with 42 CFR 485, Subpart
F. For outpatient services provided on or before June
30, 2018, the EAPG standardized amounts are determined
separately for each critical access hospital such that
simulated EAPG payments using outpatient base period
paid claim data plus payments under Section 5A-12.4 of
this Code net of the associated tax costs are equal to
the estimated costs of outpatient base period claims
data with a rate year cost inflation factor applied.
(3) In addition to the statewide-standardized amounts,
the Department shall develop adjusters to adjust the rate
of reimbursement for critical Medicaid hospital outpatient
providers or services, including outpatient high volume or
safety-net hospitals. Beginning July 1, 2018, the
outpatient high volume adjustor shall be increased to

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increase annual expenditures associated with this adjustor
by $79,200,000, based on the State Fiscal Year 2015 base
year data and this adjustor shall apply to public
hospitals, except for large public hospitals, as defined
under 89 Ill. Adm. Code 148.25(a).
(4) Beginning July 1, 2018, in addition to the
statewide standardized amounts, the Department shall make
an add-on payment for outpatient expensive devices and
drugs. This add-on payment shall at least apply to claim
lines that: (i) are assigned with one of the following
EAPGs: 490, 1001 to 1020, and coded with one of the
following revenue codes: 0274 to 0276, 0278; or (ii) are
assigned with one of the following EAPGs: 430 to 441, 443,
444, 460 to 465, 495, 496, 1090. The add-on payment shall
be calculated as follows: the claim line's covered charges
multiplied by the hospital's total acute cost to charge
ratio, less the claim line's EAPG payment plus $1,000,
multiplied by 0.8.
(5) Beginning July 1, 2018, the statewide-standardized
amounts for outpatient services shall be increased by a
uniform percentage so that base claims projected
reimbursement is increased by an amount equal to no less
than the funds allocated in paragraph (1) of subsection
(b) of Section 5A-12.6, less the amount allocated under
paragraphs (8) and (9) of subsection (a) and paragraphs
(3) and (4) of this subsection multiplied by 46%.

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(6) Effective for dates of service on or after July 1,
2018, the Department shall establish adjustments to the
statewide-standardized amounts for each Critical Access
Hospital, as designated by the Department of Public Health
in accordance with 42 CFR 485, Subpart F, such that each
Critical Access Hospital's standardized amount for
outpatient services shall be increased by the applicable
uniform percentage determined pursuant to paragraph (5) of
this subsection. It is the intent of the General Assembly
that the adjustments required under this paragraph (6) by
Public Act 100-1181 shall be applied retroactively to
claims for dates of service provided on or after July 1,
2018.
(7) Effective for dates of service on or after March
8, 2019 (the effective date of Public Act 100-1181), the
Department shall recalculate and implement an updated
statewide-standardized amount for outpatient services
provided by hospitals that are not Critical Access
Hospitals to reflect the applicable uniform percentage
determined pursuant to paragraph (5).
(1) Any recalculation to the
statewide-standardized amounts for outpatient services
provided by hospitals that are not Critical Access
Hospitals shall be the amount necessary to achieve the
increase in the statewide-standardized amounts for
outpatient services increased by a uniform percentage,

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so that base claims projected reimbursement is
increased by an amount equal to no less than the funds
allocated in paragraph (1) of subsection (b) of
Section 5A-12.6, less the amount allocated under
paragraphs (8) and (9) of subsection (a) and
paragraphs (3) and (4) of this subsection, for all
hospitals that are not Critical Access Hospitals,
multiplied by 46%.
(2) It is the intent of the General Assembly that
the recalculations required under this paragraph (7)
by Public Act 100-1181 shall be applied prospectively
to claims for dates of service provided on or after
March 8, 2019 (the effective date of Public Act
100-1181) and that no recoupment or repayment by the
Department or an MCO of payments attributable to
recalculation under this paragraph (7), issued to the
hospital for dates of service on or after July 1, 2018
and before March 8, 2019 (the effective date of Public
Act 100-1181), shall be permitted.
(8) The Department shall ensure that all necessary
adjustments to the managed care organization capitation
base rates necessitated by the adjustments under
subparagraph (6) or (7) of this subsection are completed
and applied retroactively in accordance with Section
5-30.8 of this Code within 90 days of March 8, 2019 (the
effective date of Public Act 100-1181).

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(9) Within 60 days after federal approval of the
change made to the assessment in Section 5A-2 by Public
Act 101-650, the Department shall incorporate into the
EAPG system for outpatient services those services
performed by hospitals currently billed through the
Non-Institutional Provider billing system.
(b-5) Notwithstanding any other provision of this Section,
beginning with dates of service on and after January 1, 2023,
any general acute care hospital with more than 500 outpatient
psychiatric Medicaid services to persons under 19 years of age
in any calendar year shall be paid the outpatient add-on
payment of no less than $113.
(c) In consultation with the hospital community, the
Department is authorized to replace 89 Ill. Adm. Code 152.150
as published in 38 Ill. Reg. 4980 through 4986 within 12 months
of June 16, 2014 (the effective date of Public Act 98-651). If
the Department does not replace these rules within 12 months
of June 16, 2014 (the effective date of Public Act 98-651), the
rules in effect for 152.150 as published in 38 Ill. Reg. 4980
through 4986 shall remain in effect until modified by rule by
the Department. Nothing in this subsection shall be construed
to mandate that the Department file a replacement rule.
(d) Transition period. There shall be a transition period
to the reimbursement systems authorized under this Section
that shall begin on the effective date of these systems and
continue until June 30, 2018, unless extended by rule by the

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Department. To help provide an orderly and predictable
transition to the new reimbursement systems and to preserve
and enhance access to the hospital services during this
transition, the Department shall allocate a transitional
hospital access pool of at least $290,000,000 annually so that
transitional hospital access payments are made to hospitals.
(1) After the transition period, the Department may
begin incorporating the transitional hospital access pool
into the base rate structure; however, the transitional
hospital access payments in effect on June 30, 2018 shall
continue to be paid, if continued under Section 5A-16.
(2) After the transition period, if the Department
reduces payments from the transitional hospital access
pool, it shall increase base rates, develop new adjustors,
adjust current adjustors, develop new hospital access
payments based on updated information, or any combination
thereof by an amount equal to the decreases proposed in
the transitional hospital access pool payments, ensuring
that the entire transitional hospital access pool amount
shall continue to be used for hospital payments.
(d-5) Hospital and health care transformation program. The
Department shall develop a hospital and health care
transformation program to provide financial assistance to
hospitals in transforming their services and care models to
better align with the needs of the communities they serve. The
payments authorized in this Section shall be subject to

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approval by the federal government.
(1) Phase 1. In State fiscal years 2019 through 2020,
the Department shall allocate funds from the transitional
access hospital pool to create a hospital transformation
pool of at least $262,906,870 annually and make hospital
transformation payments to hospitals. Subject to Section
5A-16, in State fiscal years 2019 and 2020, an Illinois
hospital that received either a transitional hospital
access payment under subsection (d) or a supplemental
payment under subsection (f) of this Section in State
fiscal year 2018, shall receive a hospital transformation
payment as follows:
(A) If the hospital's Rate Year 2017 Medicaid
inpatient utilization rate is equal to or greater than
45%, the hospital transformation payment shall be
equal to 100% of the sum of its transitional hospital
access payment authorized under subsection (d) and any
supplemental payment authorized under subsection (f).
(B) If the hospital's Rate Year 2017 Medicaid
inpatient utilization rate is equal to or greater than
25% but less than 45%, the hospital transformation
payment shall be equal to 75% of the sum of its
transitional hospital access payment authorized under
subsection (d) and any supplemental payment authorized
under subsection (f).
(C) If the hospital's Rate Year 2017 Medicaid

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inpatient utilization rate is less than 25%, the
hospital transformation payment shall be equal to 50%
of the sum of its transitional hospital access payment
authorized under subsection (d) and any supplemental
payment authorized under subsection (f).
(2) Phase 2.
(A) The funding amount from phase one shall be
incorporated into directed payment and pass-through
payment methodologies described in Section 5A-12.7.
(B) Because there are communities in Illinois that
experience significant health care disparities due to
systemic racism, as recently emphasized by the
COVID-19 pandemic, aggravated by social determinants
of health and a lack of sufficiently allocated health
care resources, particularly community-based services,
preventive care, obstetric care, chronic disease
management, and specialty care, the Department shall
establish a health care transformation program that
shall be supported by the transformation funding pool.
It is the intention of the General Assembly that
innovative partnerships funded by the pool must be
designed to establish or improve integrated health
care delivery systems that will provide significant
access to the Medicaid and uninsured populations in
their communities, as well as improve health care
equity. It is also the intention of the General

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Assembly that partnerships recognize and address the
disparities revealed by the COVID-19 pandemic, as well
as the need for post-COVID care. During State fiscal
years 2021 through 2027, the hospital and health care
transformation program shall be supported by an annual
transformation funding pool of up to $150,000,000,
pending federal matching funds, to be allocated during
the specified fiscal years for the purpose of
facilitating hospital and health care transformation.
Funds that had been budgeted but unexpended in State
fiscal years 2021 through 2027 may be allocated in
State fiscal year 2028 in an amount not to exceed
$150,000,000. No disbursement of moneys for
transformation projects from the transformation
funding pool described under this Section shall be
considered an award, a grant, or an expenditure of
grant funds. Funding agreements made in accordance
with the transformation program shall be considered
purchases of care under the Illinois Procurement Code,
and funds shall be expended by the Department in a
manner that maximizes federal funding to expend the
entire allocated amount.
The Department shall convene, within 30 days after
March 12, 2021 (the effective date of Public Act
101-655), a workgroup that includes subject matter
experts on health care disparities and stakeholders

10400SB3365ham001 - 120 - LRB104 18483 KTG 38682 a
from distressed communities, which could be a
subcommittee of the Medicaid Advisory Committee, to
review and provide recommendations on how Department
policy, including health care transformation, can
improve health disparities and the impact on
communities disproportionately affected by COVID-19.
The workgroup shall consider and make recommendations
on the following issues: a community safety-net
designation of certain hospitals, racial equity, and a
regional partnership to bring additional specialty
services to communities.
(C) As provided in paragraph (9) of Section 3 of
the Illinois Health Facilities Planning Act, any
hospital participating in the transformation program
may be excluded from the requirements of the Illinois
Health Facilities Planning Act for those projects
related to the hospital's transformation. To be
eligible, the hospital must submit to the Health
Facilities and Services Review Board approval from the
Department that the project is a part of the
hospital's transformation.
(D) As provided in subsection (a-20) of Section
32.5 of the Emergency Medical Services (EMS) Systems
Act, a hospital that received hospital transformation
payments under this Section may convert to a
freestanding emergency center. To be eligible for such

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a conversion, the hospital must submit to the
Department of Public Health approval from the
Department that the project is a part of the
hospital's transformation.
(E) Criteria for proposals. To be eligible for
funding under this Section, a transformation proposal
shall meet all of the following criteria:
(i) the proposal shall be designed based on
community needs assessment completed by either a
University partner or other qualified entity with
significant community input;
(ii) the proposal shall be a collaboration
among providers across the care and community
spectrum, including preventative care, primary
care, specialty care, hospital services, mental
health and substance abuse services, as well as
community-based entities that address the social
determinants of health;
(iii) the proposal shall be specifically
designed to improve health care outcomes and
reduce health care disparities, and improve the
coordination, effectiveness, and efficiency of
care delivery;
(iv) the proposal shall have specific
measurable metrics related to disparities that
will be tracked by the Department and made public

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by the Department;
(v) the proposal shall include a commitment to
include Business Enterprise Program certified
vendors or other entities controlled and managed
by minorities or women; and
(vi) the proposal shall specifically increase
access to primary, preventive, or specialty care.
(F) Entities eligible to be funded.
(i) Proposals for funding should come from
collaborations operating in one of the most
distressed communities in Illinois as determined
by the U.S. Centers for Disease Control and
Prevention's Social Vulnerability Index for
Illinois and areas disproportionately impacted by
COVID-19 or from rural areas of Illinois.
(ii) The Department shall prioritize
partnerships from distressed communities, which
include Business Enterprise Program certified
vendors or other entities controlled and managed
by minorities or women and also include one or
more of the following: safety-net hospitals,
critical access hospitals, the campuses of
hospitals that have closed since January 1, 2018,
or other health care providers designed to address
specific health care disparities, including the
impact of COVID-19 on individuals and the

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community and the need for post-COVID care. All
funded proposals must include specific measurable
goals and metrics related to improved outcomes and
reduced disparities which shall be tracked by the
Department.
(iii) The Department should target the funding
in the following ways: $30,000,000 of
transformation funds to projects that are a
collaboration between a safety-net hospital,
particularly community safety-net hospitals, and
other providers and designed to address specific
health care disparities, $20,000,000 of
transformation funds to collaborations between
safety-net hospitals and a larger hospital partner
that increases specialty care in distressed
communities, $30,000,000 of transformation funds
to projects that are a collaboration between
hospitals and other providers in distressed areas
of the State designed to address specific health
care disparities, $15,000,000 to collaborations
between critical access hospitals and other
providers designed to address specific health care
disparities, and $15,000,000 to cross-provider
collaborations designed to address specific health
care disparities, and $5,000,000 to collaborations
that focus on workforce development.

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(iv) The Department may allocate up to
$5,000,000 for planning, racial equity analysis,
or consulting resources for the Department or
entities without the resources to develop a plan
to meet the criteria of this Section. Any contract
for consulting services issued by the Department
under this subparagraph shall comply with the
provisions of Section 5-45 of the State Officials
and Employees Ethics Act. Based on availability of
federal funding, the Department may directly
procure consulting services or provide funding to
the collaboration. The provision of resources
under this subparagraph is not a guarantee that a
project will be approved.
(v) The Department shall take steps to ensure
that safety-net hospitals operating in
under-resourced communities receive priority
access to hospital and health care transformation
funds, including consulting funds, as provided
under this Section.
(G) Process for submitting and approving projects
for distressed communities. The Department shall issue
a template for application. The Department shall post
any proposal received on the Department's website for
at least 2 weeks for public comment, and any such
public comment shall also be considered in the review

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process. Applicants may request that proprietary
financial information be redacted from publicly posted
proposals and the Department in its discretion may
agree. Proposals for each distressed community must
include all of the following:
(i) A detailed description of how the project
intends to affect the goals outlined in this
subsection, describing new interventions, new
technology, new structures, and other changes to
the health care delivery system planned.
(ii) A detailed description of the racial and
ethnic makeup of the entities' board and
leadership positions and the salaries of the
executive staff of entities in the partnership
that is seeking to obtain funding under this
Section.
(iii) A complete budget, including an overall
timeline and a detailed pathway to sustainability
within a 5-year period, specifying other sources
of funding, such as in-kind, cost-sharing, or
private donations, particularly for capital needs.
There is an expectation that parties to the
transformation project dedicate resources to the
extent they are able and that these expectations
are delineated separately for each entity in the
proposal.

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(iv) A description of any new entities formed
or other legal relationships between collaborating
entities and how funds will be allocated among
participants.
(v) A timeline showing the evolution of sites
and specific services of the project over a 5-year
period, including services available to the
community by site.
(vi) Clear milestones indicating progress
toward the proposed goals of the proposal as
checkpoints along the way to continue receiving
funding. The Department is authorized to refine
these milestones in agreements, and is authorized
to impose reasonable penalties, including
repayment of funds, for substantial lack of
progress.
(vii) A clear statement of the level of
commitment the project will include for minorities
and women in contracting opportunities, including
as equity partners where applicable, or as
subcontractors and suppliers in all phases of the
project.
(viii) If the community study utilized is not
the study commissioned and published by the
Department, the applicant must define the
methodology used, including documentation of clear

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community participation.
(ix) A description of the process used in
collaborating with all levels of government in the
community served in the development of the
project, including, but not limited to,
legislators and officials of other units of local
government.
(x) Documentation of a community input process
in the community served, including links to
proposal materials on public websites.
(xi) Verifiable project milestones and quality
metrics that will be impacted by transformation.
These project milestones and quality metrics must
be identified with improvement targets that must
be met.
(xii) Data on the number of existing employees
by various job categories and wage levels by the
zip code of the employees' residence and
benchmarks for the continued maintenance and
improvement of these levels. The proposal must
also describe any retraining or other workforce
development planned for the new project.
(xiii) If a new entity is created by the
project, a description of how the board will be
reflective of the community served by the
proposal.

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(xiv) An explanation of how the proposal will
address the existing disparities that exacerbated
the impact of COVID-19 and the need for post-COVID
care in the community, if applicable.
(xv) An explanation of how the proposal is
designed to increase access to care, including
specialty care based upon the community's needs.
(H) The Department shall evaluate proposals for
compliance with the criteria listed under subparagraph
(G). Proposals meeting all of the criteria may be
eligible for funding with the areas of focus
prioritized as described in item (ii) of subparagraph
(F). Based on the funds available, the Department may
negotiate funding agreements with approved applicants
to maximize federal funding. Nothing in this
subsection requires that an approved project be funded
to the level requested. Agreements shall specify the
amount of funding anticipated annually, the
methodology of payments, the limit on the number of
years such funding may be provided, and the milestones
and quality metrics that must be met by the projects in
order to continue to receive funding during each year
of the program. Agreements shall specify the terms and
conditions under which a health care facility that
receives funds under a purchase of care agreement and
closes in violation of the terms of the agreement must

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pay an early closure fee no greater than 50% of the
funds it received under the agreement, prior to the
Health Facilities and Services Review Board
considering an application for closure of the
facility. Any project that is funded shall be required
to provide quarterly written progress reports, in a
form prescribed by the Department, and at a minimum
shall include the progress made in achieving any
milestones or metrics or Business Enterprise Program
commitments in its plan. The Department may reduce or
end payments, as set forth in transformation plans, if
milestones or metrics or Business Enterprise Program
commitments are not achieved. The Department shall
seek to make payments from the transformation fund in
a manner that is eligible for federal matching funds.
In reviewing the proposals, the Department shall
take into account the needs of the community, data
from the study commissioned by the Department from the
University of Illinois-Chicago if applicable, feedback
from public comment on the Department's website, as
well as how the proposal meets the criteria listed
under subparagraph (G). Alignment with the
Department's overall strategic initiatives shall be an
important factor. To the extent that fiscal year
funding is not adequate to fund all eligible projects
that apply, the Department shall prioritize

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applications that most comprehensively and effectively
address the criteria listed under subparagraph (G).
(3) (Blank).
(4) Hospital Transformation Review Committee. There is
created the Hospital Transformation Review Committee. The
Committee shall consist of 14 members. No later than 30
days after March 12, 2018 (the effective date of Public
Act 100-581), the 4 legislative leaders shall each appoint
3 members; the Governor shall appoint the Director of
Healthcare and Family Services, or his or her designee, as
a member; and the Director of Healthcare and Family
Services shall appoint one member. Any vacancy shall be
filled by the applicable appointing authority within 15
calendar days. The members of the Committee shall select a
Chair and a Vice-Chair from among its members, provided
that the Chair and Vice-Chair cannot be appointed by the
same appointing authority and must be from different
political parties. The Chair shall have the authority to
establish a meeting schedule and convene meetings of the
Committee, and the Vice-Chair shall have the authority to
convene meetings in the absence of the Chair. The
Committee may establish its own rules with respect to
meeting schedule, notice of meetings, and the disclosure
of documents; however, the Committee shall not have the
power to subpoena individuals or documents and any rules
must be approved by 9 of the 14 members. The Committee

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shall perform the functions described in this Section and
advise and consult with the Director in the administration
of this Section. In addition to reviewing and approving
the policies, procedures, and rules for the hospital and
health care transformation program, the Committee shall
consider and make recommendations related to qualifying
criteria and payment methodologies related to safety-net
hospitals and children's hospitals. Members of the
Committee appointed by the legislative leaders shall be
subject to the jurisdiction of the Legislative Ethics
Commission, not the Executive Ethics Commission, and all
requests under the Freedom of Information Act shall be
directed to the applicable Freedom of Information officer
for the General Assembly. The Department shall provide
operational support to the Committee as necessary. The
Committee is dissolved on April 1, 2019.
(e) Beginning 36 months after initial implementation, the
Department shall update the reimbursement components in
subsections (a) and (b), including standardized amounts and
weighting factors, and at least once every 4 years and no more
frequently than annually thereafter. The Department shall
publish these updates on its website no later than 30 calendar
days prior to their effective date.
(f) Continuation of supplemental payments. Any
supplemental payments authorized under 89 Illinois
Administrative Code 148 effective January 1, 2014 and that

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continue during the period of July 1, 2014 through December
31, 2014 shall remain in effect as long as the assessment
imposed by Section 5A-2 that is in effect on December 31, 2017
remains in effect.
(g) Notwithstanding subsections (a) through (f) of this
Section and notwithstanding the changes authorized under
Section 5-5b.1, any updates to the system shall not result in
any diminishment of the overall effective rates of
reimbursement as of the implementation date of the new system
(July 1, 2014). These updates shall not preclude variations in
any individual component of the system or hospital rate
variations. Nothing in this Section shall prohibit the
Department from increasing the rates of reimbursement or
developing payments to ensure access to hospital services.
Nothing in this Section shall be construed to guarantee a
minimum amount of spending in the aggregate or per hospital as
spending may be impacted by factors, including, but not
limited to, the number of individuals in the medical
assistance program and the severity of illness of the
individuals.
(h) The Department shall have the authority to modify by
rulemaking any changes to the rates or methodologies in this
Section as required by the federal government to obtain
federal financial participation for expenditures made under
this Section.
(i) Except for subsections (g) and (h) of this Section,

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the Department shall, pursuant to subsection (c) of Section
5-40 of the Illinois Administrative Procedure Act, provide for
presentation at the June 2014 hearing of the Joint Committee
on Administrative Rules (JCAR) additional written notice to
JCAR of the following rules in order to commence the second
notice period for the following rules: rules published in the
Illinois Register, rule dated February 21, 2014 at 38 Ill.
Reg. 4559 (Medical Payment), 4628 (Specialized Health Care
Delivery Systems), 4640 (Hospital Services), 4932 (Diagnostic
Related Grouping (DRG) Prospective Payment System (PPS)), and
4977 (Hospital Reimbursement Changes), and published in the
Illinois Register dated March 21, 2014 at 38 Ill. Reg. 6499
(Specialized Health Care Delivery Systems) and 6505 (Hospital
Services).
(j) Out-of-state hospitals. Beginning July 1, 2018, for
purposes of determining for State fiscal years 2019 and 2020
and subsequent fiscal years the hospitals eligible for the
payments authorized under subsections (a) and (b) of this
Section, the Department shall include out-of-state hospitals
that are designated a Level I pediatric trauma center or a
Level I trauma center by the Department of Public Health as of
December 1, 2017.
(k) The Department shall notify each hospital and managed
care organization, in writing, of the impact of the updates
under this Section at least 30 calendar days prior to their
effective date.

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(k-5) The Department shall adopt amended rules, in advance
of the development of annual Calendar Year 2027 hospital
rates, to address the standardized process and time frame for
updates to the reimbursement components described in
subsections (a) and (b), including, but not limited to, the
definition of "excessive growth" in paragraph (4) of
subsection (a), in consultation with a statewide association
representing a majority of hospitals, to be undertaken prior
to initiating rulemaking in accordance with the Illinois
Administrative Procedure Act.
(l) This Section is subject to Section 14-12.5.
(Source: P.A. 103-102, eff. 6-16-23; 103-154, eff. 6-30-23;
104-9, eff. 6-16-25; 104-417, eff. 8-15-25.)
ARTICLE 30.
Section 30-5. The Illinois Public Aid Code is amended by
changing Section 12-9 as follows:
(305 ILCS 5/12-9) (from Ch. 23, par. 12-9)
Sec. 12-9. Public Aid Recoveries Trust Fund; uses. The
Public Aid Recoveries Trust Fund shall consist of (1)
recoveries by the Department of Healthcare and Family Services
(formerly Illinois Department of Public Aid) authorized by
this Code in respect to applicants or recipients under
Articles III, IV, V, and VI, including recoveries made by the

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Department of Healthcare and Family Services (formerly
Illinois Department of Public Aid) from the estates of
deceased recipients, (2) recoveries made by the Department of
Healthcare and Family Services (formerly Illinois Department
of Public Aid) in respect to applicants and recipients under
the Children's Health Insurance Program Act, and the Covering
ALL KIDS Health Insurance Act, (2.5) recoveries made by the
Department of Healthcare and Family Services in connection
with the imposition of an administrative penalty as provided
under Section 12-4.45, (3) federal funds received on behalf of
and earned by State universities, other State agencies or
departments, and local governmental entities for services
provided to applicants or recipients covered under this Code,
the Children's Health Insurance Program Act, and the Covering
ALL KIDS Health Insurance Act, (3.5) federal financial
participation revenue related to eligible disbursements made
by the Department of Healthcare and Family Services from
appropriations required by this Section, and (4) all other
moneys received to the Fund, including interest thereon. The
Fund shall be held as a special fund in the State Treasury.
Disbursements from this Fund shall be only (1) for the
reimbursement of claims collected by the Department of
Healthcare and Family Services (formerly Illinois Department
of Public Aid) through error or mistake, (2) for payment to
persons or agencies designated as payees or co-payees on any
instrument, whether or not negotiable, delivered to the

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Department of Healthcare and Family Services (formerly
Illinois Department of Public Aid) as a recovery under this
Section, such payment to be in proportion to the respective
interests of the payees in the amount so collected, (3) for
payments to the Department of Human Services for collections
made by the Department of Healthcare and Family Services
(formerly Illinois Department of Public Aid) on behalf of the
Department of Human Services under this Code, the Children's
Health Insurance Program Act, and the Covering ALL KIDS Health
Insurance Act, (4) for payment of administrative expenses
incurred in performing the activities authorized under this
Code, the Children's Health Insurance Program Act, and the
Covering ALL KIDS Health Insurance Act, (5) for payment of
fees to persons or agencies in the performance of activities
pursuant to the collection of monies owed the State that are
collected under this Code, the Children's Health Insurance
Program Act, and the Covering ALL KIDS Health Insurance Act,
(6) separate from those disbursements allowed under items (4)
and (5), for payment of contingency fees to third-party
entities that the Office of Inspector General authorizes to
conduct audits under Sections 12-4.25 and 12-4.40, or any
similar audits required by State or federal law, (7) for
payments of any amounts which are reimbursable to the federal
government which are required to be paid by State warrant by
either the State or federal government, and (8) (7) for
payments to State universities, other State agencies or

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departments, and local governmental entities of federal funds
for services provided to applicants or recipients covered
under this Code, the Children's Health Insurance Program Act,
and the Covering ALL KIDS Health Insurance Act. Disbursements
from this Fund for purposes of items (4) and (5) of this
paragraph shall be subject to appropriations from the Fund to
the Department of Healthcare and Family Services (formerly
Illinois Department of Public Aid).
The balance in this Fund after payment therefrom of any
amounts reimbursable to the federal government, and minus the
amount anticipated to be needed to make the disbursements
authorized by this Section, shall be certified by the Director
of Healthcare and Family Services and transferred by the State
Comptroller to the Drug Rebate Fund or the Healthcare Provider
Relief Fund in the State Treasury, as appropriate, on at least
an annual basis by June 30th of each fiscal year. The Director
of Healthcare and Family Services may certify and the State
Comptroller shall transfer to the Drug Rebate Fund or the
Healthcare Provider Relief Fund amounts on a more frequent
basis.
(Source: P.A. 103-593, eff. 6-7-24.)
ARTICLE 35.
Section 35-5. The Illinois Public Aid Code is amended by
changing Section 5-5.4 as follows:

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(305 ILCS 5/5-5.4) (from Ch. 23, par. 5-5.4)
Sec. 5-5.4. Standards of payment; Department of Healthcare
and Family Services. The Department of Healthcare and Family
Services shall develop standards of payment of nursing
facility and ICF/DD services in facilities providing such
services under this Article which:
(1) Provide for the determination of a facility's payment
for nursing facility or ICF/DD services on a prospective
basis. The amount of the payment rate for all nursing
facilities certified by the Department of Public Health under
the ID/DD Community Care Act or the Nursing Home Care Act as
Intermediate Care for the Developmentally Disabled facilities,
Long Term Care for Under Age 22 facilities, Skilled Nursing
facilities, or Intermediate Care facilities under the medical
assistance program shall be prospectively established annually
on the basis of historical, financial, and statistical data
reflecting actual costs from prior years, which shall be
applied to the current rate year and updated for inflation,
except that the capital cost element for newly constructed
facilities shall be based upon projected budgets. The annually
established payment rate shall take effect on July 1 in 1984
and subsequent years. No rate increase and no update for
inflation shall be provided on or after July 1, 1994, unless
specifically provided for in this Section. The changes made by
Public Act 93-841 extending the duration of the prohibition

10400SB3365ham001 - 139 - LRB104 18483 KTG 38682 a
against a rate increase or update for inflation are effective
retroactive to July 1, 2004.
For facilities licensed by the Department of Public Health
under the Nursing Home Care Act as Intermediate Care for the
Developmentally Disabled facilities or Long Term Care for
Under Age 22 facilities, the rates taking effect on July 1,
1998 shall include an increase of 3%. For facilities licensed
by the Department of Public Health under the Nursing Home Care
Act as Skilled Nursing facilities or Intermediate Care
facilities, the rates taking effect on July 1, 1998 shall
include an increase of 3% plus $1.10 per resident-day, as
defined by the Department. For facilities licensed by the
Department of Public Health under the Nursing Home Care Act as
Intermediate Care Facilities for the Developmentally Disabled
or Long Term Care for Under Age 22 facilities, the rates taking
effect on January 1, 2006 shall include an increase of 3%. For
facilities licensed by the Department of Public Health under
the Nursing Home Care Act as Intermediate Care Facilities for
the Developmentally Disabled or Long Term Care for Under Age
22 facilities, the rates taking effect on January 1, 2009
shall include an increase sufficient to provide a $0.50 per
hour wage increase for non-executive staff. For facilities
licensed by the Department of Public Health under the ID/DD
Community Care Act as ID/DD Facilities the rates taking effect
within 30 days after July 6, 2017 (the effective date of Public
Act 100-23) shall include an increase sufficient to provide a

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$0.75 per hour wage increase for non-executive staff. The
Department shall adopt rules, including emergency rules under
subsection (y) of Section 5-45 of the Illinois Administrative
Procedure Act, to implement the provisions of this paragraph.
For facilities licensed by the Department of Public Health
under the ID/DD Community Care Act as ID/DD Facilities and
under the MC/DD Act as MC/DD Facilities, the rates taking
effect within 30 days after June 5, 2019 (the effective date of
Public Act 101-10) shall include an increase sufficient to
provide a $0.50 per hour wage increase for non-executive
frontline personnel, including, but not limited to, direct
support persons, aides, frontline supervisors, qualified
intellectual disabilities professionals, nurses, and
non-administrative support staff. The Department shall adopt
rules, including emergency rules under subsection (bb) of
Section 5-45 of the Illinois Administrative Procedure Act, to
implement the provisions of this paragraph.
For facilities licensed by the Department of Public Health
under the Nursing Home Care Act as Intermediate Care for the
Developmentally Disabled facilities or Long Term Care for
Under Age 22 facilities, the rates taking effect on July 1,
1999 shall include an increase of 1.6% plus $3.00 per
resident-day, as defined by the Department. For facilities
licensed by the Department of Public Health under the Nursing
Home Care Act as Skilled Nursing facilities or Intermediate
Care facilities, the rates taking effect on July 1, 1999 shall

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include an increase of 1.6% and, for services provided on or
after October 1, 1999, shall be increased by $4.00 per
resident-day, as defined by the Department.
For facilities licensed by the Department of Public Health
under the Nursing Home Care Act as Intermediate Care for the
Developmentally Disabled facilities or Long Term Care for
Under Age 22 facilities, the rates taking effect on July 1,
2000 shall include an increase of 2.5% per resident-day, as
defined by the Department. For facilities licensed by the
Department of Public Health under the Nursing Home Care Act as
Skilled Nursing facilities or Intermediate Care facilities,
the rates taking effect on July 1, 2000 shall include an
increase of 2.5% per resident-day, as defined by the
Department.
For facilities licensed by the Department of Public Health
under the Nursing Home Care Act as skilled nursing facilities
or intermediate care facilities, a new payment methodology
must be implemented for the nursing component of the rate
effective July 1, 2003. The Department of Public Aid (now
Healthcare and Family Services) shall develop the new payment
methodology using the Minimum Data Set (MDS) as the instrument
to collect information concerning nursing home resident
condition necessary to compute the rate. The Department shall
develop the new payment methodology to meet the unique needs
of Illinois nursing home residents while remaining subject to
the appropriations provided by the General Assembly. A

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transition period from the payment methodology in effect on
June 30, 2003 to the payment methodology in effect on July 1,
2003 shall be provided for a period not exceeding 3 years and
184 days after implementation of the new payment methodology
as follows:
(A) For a facility that would receive a lower nursing
component rate per patient day under the new system than
the facility received effective on the date immediately
preceding the date that the Department implements the new
payment methodology, the nursing component rate per
patient day for the facility shall be held at the level in
effect on the date immediately preceding the date that the
Department implements the new payment methodology until a
higher nursing component rate of reimbursement is achieved
by that facility.
(B) For a facility that would receive a higher nursing
component rate per patient day under the payment
methodology in effect on July 1, 2003 than the facility
received effective on the date immediately preceding the
date that the Department implements the new payment
methodology, the nursing component rate per patient day
for the facility shall be adjusted.
(C) Notwithstanding paragraphs (A) and (B), the
nursing component rate per patient day for the facility
shall be adjusted subject to appropriations provided by
the General Assembly.

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For facilities licensed by the Department of Public Health
under the Nursing Home Care Act as Intermediate Care for the
Developmentally Disabled facilities or Long Term Care for
Under Age 22 facilities, the rates taking effect on March 1,
2001 shall include a statewide increase of 7.85%, as defined
by the Department.
Notwithstanding any other provision of this Section, for
facilities licensed by the Department of Public Health under
the Nursing Home Care Act as skilled nursing facilities or
intermediate care facilities, except facilities participating
in the Department's demonstration program pursuant to the
provisions of Title 77, Part 300, Subpart T of the Illinois
Administrative Code, the numerator of the ratio used by the
Department of Healthcare and Family Services to compute the
rate payable under this Section using the Minimum Data Set
(MDS) methodology shall incorporate the following annual
amounts as the additional funds appropriated to the Department
specifically to pay for rates based on the MDS nursing
component methodology in excess of the funding in effect on
December 31, 2006:
(i) For rates taking effect January 1, 2007,
$60,000,000.
(ii) For rates taking effect January 1, 2008,
$110,000,000.
(iii) For rates taking effect January 1, 2009,
$194,000,000.

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(iv) For rates taking effect April 1, 2011, or the
first day of the month that begins at least 45 days after
February 16, 2011 (the effective date of Public Act
96-1530), $416,500,000 or an amount as may be necessary to
complete the transition to the MDS methodology for the
nursing component of the rate. Increased payments under
this item (iv) are not due and payable, however, until (i)
the methodologies described in this paragraph are approved
by the federal government in an appropriate State Plan
amendment and (ii) the assessment imposed by Section 5B-2
of this Code is determined to be a permissible tax under
Title XIX of the Social Security Act.
Notwithstanding any other provision of this Section, for
facilities licensed by the Department of Public Health under
the Nursing Home Care Act as skilled nursing facilities or
intermediate care facilities, the support component of the
rates taking effect on January 1, 2008 shall be computed using
the most recent cost reports on file with the Department of
Healthcare and Family Services no later than April 1, 2005,
updated for inflation to January 1, 2006.
For facilities licensed by the Department of Public Health
under the Nursing Home Care Act as Intermediate Care for the
Developmentally Disabled facilities or Long Term Care for
Under Age 22 facilities, the rates taking effect on April 1,
2002 shall include a statewide increase of 2.0%, as defined by
the Department. This increase terminates on July 1, 2002;

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beginning July 1, 2002 these rates are reduced to the level of
the rates in effect on March 31, 2002, as defined by the
Department.
For facilities licensed by the Department of Public Health
under the Nursing Home Care Act as skilled nursing facilities
or intermediate care facilities, the rates taking effect on
July 1, 2001 shall be computed using the most recent cost
reports on file with the Department of Public Aid no later than
April 1, 2000, updated for inflation to January 1, 2001. For
rates effective July 1, 2001 only, rates shall be the greater
of the rate computed for July 1, 2001 or the rate effective on
June 30, 2001.
Notwithstanding any other provision of this Section, for
facilities licensed by the Department of Public Health under
the Nursing Home Care Act as skilled nursing facilities or
intermediate care facilities, the Illinois Department shall
determine by rule the rates taking effect on July 1, 2002,
which shall be 5.9% less than the rates in effect on June 30,
2002.
Notwithstanding any other provision of this Section, for
facilities licensed by the Department of Public Health under
the Nursing Home Care Act as skilled nursing facilities or
intermediate care facilities, if the payment methodologies
required under Section 5A-12 and the waiver granted under 42
CFR 433.68 are approved by the United States Centers for
Medicare and Medicaid Services, the rates taking effect on

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July 1, 2004 shall be 3.0% greater than the rates in effect on
June 30, 2004. These rates shall take effect only upon
approval and implementation of the payment methodologies
required under Section 5A-12.
Notwithstanding any other provisions of this Section, for
facilities licensed by the Department of Public Health under
the Nursing Home Care Act as skilled nursing facilities or
intermediate care facilities, the rates taking effect on
January 1, 2005 shall be 3% more than the rates in effect on
December 31, 2004.
Notwithstanding any other provision of this Section, for
facilities licensed by the Department of Public Health under
the Nursing Home Care Act as skilled nursing facilities or
intermediate care facilities, effective January 1, 2009, the
per diem support component of the rates effective on January
1, 2008, computed using the most recent cost reports on file
with the Department of Healthcare and Family Services no later
than April 1, 2005, updated for inflation to January 1, 2006,
shall be increased to the amount that would have been derived
using standard Department of Healthcare and Family Services
methods, procedures, and inflators.
Notwithstanding any other provisions of this Section, for
facilities licensed by the Department of Public Health under
the Nursing Home Care Act as intermediate care facilities that
are federally defined as Institutions for Mental Disease, or
facilities licensed by the Department of Public Health under

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the Specialized Mental Health Rehabilitation Act of 2013, a
socio-development component rate equal to 6.6% of the
facility's nursing component rate as of January 1, 2006 shall
be established and paid effective July 1, 2006. The
socio-development component of the rate shall be increased by
a factor of 2.53 on the first day of the month that begins at
least 45 days after January 11, 2008 (the effective date of
Public Act 95-707). As of August 1, 2008, the
socio-development component rate shall be equal to 6.6% of the
facility's nursing component rate as of January 1, 2006,
multiplied by a factor of 3.53. For services provided on or
after April 1, 2011, or the first day of the month that begins
at least 45 days after February 16, 2011 (the effective date of
Public Act 96-1530), whichever is later, the Illinois
Department may by rule adjust these socio-development
component rates, and may use different adjustment
methodologies for those facilities participating, and those
not participating, in the Illinois Department's demonstration
program pursuant to the provisions of Title 77, Part 300,
Subpart T of the Illinois Administrative Code, but in no case
may such rates be diminished below those in effect on August 1,
2008.
For facilities licensed by the Department of Public Health
under the Nursing Home Care Act as Intermediate Care for the
Developmentally Disabled facilities or as long-term care
facilities for residents under 22 years of age, the rates

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taking effect on July 1, 2003 shall include a statewide
increase of 4%, as defined by the Department.
For facilities licensed by the Department of Public Health
under the Nursing Home Care Act as Intermediate Care for the
Developmentally Disabled facilities or Long Term Care for
Under Age 22 facilities, the rates taking effect on the first
day of the month that begins at least 45 days after January 11,
2008 (the effective date of Public Act 95-707) shall include a
statewide increase of 2.5%, as defined by the Department.
Notwithstanding any other provision of this Section, for
facilities licensed by the Department of Public Health under
the Nursing Home Care Act as skilled nursing facilities or
intermediate care facilities, effective January 1, 2005,
facility rates shall be increased by the difference between
(i) a facility's per diem property, liability, and malpractice
insurance costs as reported in the cost report filed with the
Department of Public Aid and used to establish rates effective
July 1, 2001 and (ii) those same costs as reported in the
facility's 2002 cost report. These costs shall be passed
through to the facility without caps or limitations, except
for adjustments required under normal auditing procedures.
Rates established effective each July 1 shall govern
payment for services rendered throughout that fiscal year,
except that rates established on July 1, 1996 shall be
increased by 6.8% for services provided on or after January 1,
1997. Such rates will be based upon the rates calculated for

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the year beginning July 1, 1990, and for subsequent years
thereafter until June 30, 2001 shall be based on the facility
cost reports for the facility fiscal year ending at any point
in time during the previous calendar year, updated to the
midpoint of the rate year. The cost report shall be on file
with the Department no later than April 1 of the current rate
year. Should the cost report not be on file by April 1, the
Department shall base the rate on the latest cost report filed
by each skilled care facility and intermediate care facility,
updated to the midpoint of the current rate year. In
determining rates for services rendered on and after July 1,
1985, fixed time shall not be computed at less than zero. The
Department shall not make any alterations of regulations which
would reduce any component of the Medicaid rate to a level
below what that component would have been utilizing in the
rate effective on July 1, 1984.
(2) Shall take into account the actual costs incurred by
facilities in providing services for recipients of skilled
nursing and intermediate care services under the medical
assistance program.
(3) Shall take into account the medical and psycho-social
characteristics and needs of the patients.
(4) Shall take into account the actual costs incurred by
facilities in meeting licensing and certification standards
imposed and prescribed by the State of Illinois, any of its
political subdivisions or municipalities and by the U.S.

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Department of Health and Human Services pursuant to Title XIX
of the Social Security Act.
The Department of Healthcare and Family Services shall
develop precise standards for payments to reimburse nursing
facilities for any utilization of appropriate rehabilitative
personnel for the provision of rehabilitative services which
is authorized by federal regulations, including reimbursement
for services provided by qualified therapists or qualified
assistants, and which is in accordance with accepted
professional practices. Reimbursement also may be made for
utilization of other supportive personnel under appropriate
supervision.
The Department shall develop enhanced payments to offset
the additional costs incurred by a facility serving
exceptional need residents and shall allocate at least
$4,000,000 of the funds collected from the assessment
established by Section 5B-2 of this Code for such payments.
For the purpose of this Section, "exceptional needs" means,
but need not be limited to, ventilator care and traumatic
brain injury care. The enhanced payments for exceptional need
residents under this paragraph are not due and payable,
however, until (i) the methodologies described in this
paragraph are approved by the federal government in an
appropriate State Plan amendment and (ii) the assessment
imposed by Section 5B-2 of this Code is determined to be a
permissible tax under Title XIX of the Social Security Act.

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Beginning January 1, 2014 the methodologies for
reimbursement of nursing facility services as provided under
this Section 5-5.4 shall no longer be applicable for services
provided on or after January 1, 2014.
No payment increase under this Section for the MDS
methodology, exceptional care residents, or the
socio-development component rate established by Public Act
96-1530 of the 96th General Assembly and funded by the
assessment imposed under Section 5B-2 of this Code shall be
due and payable until after the Department notifies the
long-term care providers, in writing, that the payment
methodologies to long-term care providers required under this
Section have been approved by the Centers for Medicare and
Medicaid Services of the U.S. Department of Health and Human
Services and the waivers under 42 CFR 433.68 for the
assessment imposed by this Section, if necessary, have been
granted by the Centers for Medicare and Medicaid Services of
the U.S. Department of Health and Human Services. Upon
notification to the Department of approval of the payment
methodologies required under this Section and the waivers
granted under 42 CFR 433.68, all increased payments otherwise
due under this Section prior to the date of notification shall
be due and payable within 90 days of the date federal approval
is received.
On and after July 1, 2012, the Department shall reduce any
rate of reimbursement for services or other payments or alter

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any methodologies authorized by this Code to reduce any rate
of reimbursement for services or other payments in accordance
with Section 5-5e.
For facilities licensed by the Department of Public Health
under the ID/DD Community Care Act as ID/DD Facilities and
under the MC/DD Act as MC/DD Facilities, subject to federal
approval, the rates taking effect for services delivered on or
after August 1, 2019 shall be increased by 3.5% over the rates
in effect on June 30, 2019. The Department shall adopt rules,
including emergency rules under subsection (ii) of Section
5-45 of the Illinois Administrative Procedure Act, to
implement the provisions of this Section, including wage
increases for direct care staff.
For facilities licensed by the Department of Public Health
under the ID/DD Community Care Act as ID/DD Facilities and
under the MC/DD Act as MC/DD Facilities, subject to federal
approval, the rates taking effect on the latter of the
approval date of the State Plan Amendment for these facilities
or the Waiver Amendment for the home and community-based
services settings shall include an increase sufficient to
provide a $0.26 per hour wage increase to the base wage for
non-executive staff. The Department shall adopt rules,
including emergency rules as authorized by Section 5-45 of the
Illinois Administrative Procedure Act, to implement the
provisions of this Section, including wage increases for
direct care staff.

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For facilities licensed by the Department of Public Health
under the ID/DD Community Care Act as ID/DD Facilities and
under the MC/DD Act as MC/DD Facilities, subject to federal
approval of the State Plan Amendment and the Waiver Amendment
for the home and community-based services settings, the rates
taking effect for the services delivered on or after July 1,
2020 shall include an increase sufficient to provide a $1.00
per hour wage increase for non-executive staff. For services
delivered on or after January 1, 2021, subject to federal
approval of the State Plan Amendment and the Waiver Amendment
for the home and community-based services settings, shall
include an increase sufficient to provide a $0.50 per hour
increase for non-executive staff. The Department shall adopt
rules, including emergency rules as authorized by Section 5-45
of the Illinois Administrative Procedure Act, to implement the
provisions of this Section, including wage increases for
direct care staff.
For facilities licensed by the Department of Public Health
under the ID/DD Community Care Act as ID/DD Facilities and
under the MC/DD Act as MC/DD Facilities, subject to federal
approval of the State Plan Amendment, the rates taking effect
for the residential services delivered on or after July 1,
2021, shall include an increase sufficient to provide a $0.50
per hour increase for aides in the rate methodology. For
facilities licensed by the Department of Public Health under
the ID/DD Community Care Act as ID/DD Facilities and under the

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MC/DD Act as MC/DD Facilities, subject to federal approval of
the State Plan Amendment, the rates taking effect for the
residential services delivered on or after January 1, 2022
shall include an increase sufficient to provide a $1.00 per
hour increase for aides in the rate methodology. In addition,
for residential services delivered on or after January 1, 2022
such rates shall include an increase sufficient to provide
wages for all residential non-executive direct care staff,
excluding aides, at the federal Department of Labor, Bureau of
Labor Statistics' average wage as defined in rule by the
Department. The Department shall adopt rules, including
emergency rules as authorized by Section 5-45 of the Illinois
Administrative Procedure Act, to implement the provisions of
this Section.
For facilities licensed by the Department of Public Health
under the ID/DD Community Care Act as ID/DD facilities and
under the MC/DD Act as MC/DD facilities, subject to federal
approval of the State Plan Amendment, the rates taking effect
for services delivered on or after January 1, 2023, shall
include a $1.00 per hour wage increase for all direct support
personnel and all other frontline personnel who are not
subject to the Bureau of Labor Statistics' average wage
increases, who work in residential and community day services
settings, with at least $0.50 of those funds to be provided as
a direct increase to all aide base wages, with the remaining
$0.50 to be used flexibly for base wage increases to the rate

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methodology for aides. In addition, for residential services
delivered on or after January 1, 2023 the rates shall include
an increase sufficient to provide wages for all residential
non-executive direct care staff, excluding aides, at the
federal Department of Labor, Bureau of Labor Statistics'
average wage as determined by the Department. Also, for
services delivered on or after January 1, 2023, the rates will
include adjustments to employment-related expenses as defined
in rule by the Department. The Department shall adopt rules,
including emergency rules as authorized by Section 5-45 of the
Illinois Administrative Procedure Act, to implement the
provisions of this Section.
For facilities licensed by the Department of Public Health
under the ID/DD Community Care Act as ID/DD facilities and
under the MC/DD Act as MC/DD facilities, subject to federal
approval of the State Plan Amendment, the rates taking effect
for services delivered on or after January 1, 2024 shall
include a $2.50 per hour wage increase for all direct support
personnel and all other frontline personnel who are not
subject to the Bureau of Labor Statistics' average wage
increases and who work in residential and community day
services settings. At least $1.25 of the per hour wage
increase shall be provided as a direct increase to all aide
base wages, and the remaining $1.25 of the per hour wage
increase shall be used flexibly for base wage increases to the
rate methodology for aides. In addition, for residential

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services delivered on or after January 1, 2024, the rates
shall include an increase sufficient to provide wages for all
residential non-executive direct care staff, excluding aides,
at the federal Department of Labor, Bureau of Labor
Statistics' average wage as determined by the Department.
Also, for services delivered on or after January 1, 2024, the
rates will include adjustments to employment-related expenses
as defined in rule by the Department. The Department shall
adopt rules, including emergency rules as authorized by
Section 5-45 of the Illinois Administrative Procedure Act, to
implement the provisions of this Section.
For facilities licensed by the Department of Public Health
under the ID/DD Community Care Act as ID/DD facilities and
under the MC/DD Act as MC/DD facilities, subject to federal
approval of a State Plan Amendment, the rates taking effect
for services delivered on or after January 1, 2025 shall
include a $1.00 per hour wage increase for all direct support
personnel and all other frontline personnel who are not
subject to the Bureau of Labor Statistics' average wage
increases and who work in residential and community day
services settings, with at least $0.75 of those funds to be
provided as a direct increase to all aide base wages and the
remaining $0.25 to be used flexibly for base wage increases to
the rate methodology for aides. These increases shall not be
used by facilities for operational and administrative
expenses. In addition, for residential services delivered on

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or after January 1, 2025, the rates shall include an increase
sufficient to provide wages for all residential non-executive
direct care staff, excluding aides, at the federal Department
of Labor, Bureau of Labor Statistics' average wage as
determined by the Department. Also, for services delivered on
or after January 1, 2025, the rates will include adjustments
to employment-related expenses as defined in rule by the
Department. The Department shall adopt rules, including
emergency rules as authorized by Section 5-45 of the Illinois
Administrative Procedure Act, to implement the provisions of
this Section.
For facilities licensed by the Department of Public Health
under the ID/DD Community Care Act as ID/DD facilities and
under the MC/DD Act as MC/DD facilities, subject to federal
approval of a State Plan Amendment, the rates taking effect
for services delivered on or after January 1, 2026 shall
include a $0.80 per hour wage increase for all direct support
personnel and all other frontline personnel who are not
subject to the Bureau of Labor Statistics' average wage
increases and who work in residential and community day
services settings, with at least $0.60 of those funds to be
provided as a direct increase to all aide base wages and the
remaining $0.20 to be used flexibly for base wage increases to
the rate methodology for aides. These increases shall not be
used by facilities for operational and administrative
expenses. In addition, for residential services delivered on

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or after January 1, 2026, the rates shall include an increase
sufficient to provide wages for all residential non-executive
direct care staff, excluding aides, at the federal Department
of Labor, Bureau of Labor Statistics' average wage as
determined by the Department. Also, for services delivered on
or after January 1, 2026, the rates will include adjustments
to employment-related expenses as defined in rule by the
Department. The Department shall adopt rules, including
emergency rules as authorized by Section 5-45 of the Illinois
Administrative Procedure Act, to implement the provisions of
this Section.
Notwithstanding any other provision of this Section to the
contrary, any regional wage adjuster for facilities located
outside of the counties of Cook, DuPage, Kane, Lake, McHenry,
and Will shall be no lower than 1.00, and any regional wage
adjuster for facilities located within the counties of Cook,
DuPage, Kane, Lake, McHenry, and Will shall be no lower than
1.15.
(5) For dates of service starting July 1, 2027,
reimbursement calculations and direct payments for services
provided by facilities licensed under the ID/DD Community Care
Act are the responsibility of the Department of Healthcare and
Family Services. Appropriations for facilities licensed under
the ID/DD Community Care Act must be shifted from the
Department of Human Services to the Department of Healthcare
and Family Services. Nothing in this Section shall prohibit

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the Department of Healthcare and Family Services from paying
more than the rates specified in this Section. Nothing in this
Section shall affect the requirements of Section 3-213 of the
ID/DD Community Care Act.
(Source: P.A. 103-8, eff. 6-7-23; 103-588, eff. 7-1-24; 104-2,
eff. 6-16-25.)
ARTICLE 40.
Section 40-5. The Illinois Public Aid Code is amended by
changing Section 5-5e.1 as follows:
(305 ILCS 5/5-5e.1)
Sec. 5-5e.1. Safety-Net Hospitals.
(a) A Safety-Net Hospital is an Illinois hospital that:
(1) is licensed by the Department of Public Health as
a general acute care or pediatric hospital; and
(2) is a disproportionate share hospital, as described
in Section 1923 of the federal Social Security Act, as
determined by the Department; and
(3) meets one of the following:
(A) has a MIUR of at least 40% and a charity
percent of at least 4%; or
(B) has a MIUR of at least 50%.
(b) Definitions. As used in this Section:
(1) "Charity percent" means the ratio of (i) the

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hospital's charity charges for services provided to
individuals without health insurance or another source of
third party coverage to (ii) the Illinois total hospital
charges, each as reported on the hospital's OBRA form.
(2) "MIUR" means Medicaid Inpatient Utilization Rate
and is defined as a fraction, the numerator of which is the
number of a hospital's inpatient days provided in the
hospital's fiscal year ending 3 years prior to the rate
year, to patients who, for such days, were eligible for
Medicaid under Title XIX of the federal Social Security
Act, 42 USC 1396a et seq., excluding those persons
eligible for medical assistance pursuant to 42 U.S.C.
1396a(a)(10)(A)(i)(VIII) as set forth in paragraph 18 of
Section 5-2 of this Article, and the denominator of which
is the total number of the hospital's inpatient days in
that same period, excluding those persons eligible for
medical assistance pursuant to 42 U.S.C.
1396a(a)(10)(A)(i)(VIII) as set forth in paragraph 18 of
Section 5-2 of this Article.
(3) "OBRA form" means form HFS-3834, OBRA '93 data
collection form, for the rate year.
(4) "Rate year" means the 12-month period beginning on
October 1.
(c) Beginning July 1, 2012 and ending on December 31, 2028
2026, a hospital that would have qualified for the rate year
beginning October 1, 2011 or October 1, 2012 shall be a

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Safety-Net Hospital.
(c-5) Beginning July 1, 2020 and ending on December 31,
2026, a hospital that would have qualified for the rate year
beginning October 1, 2020 and was designated a federal rural
referral center under 42 CFR 412.96 as of October 1, 2020 shall
be a Safety-Net Hospital.
(d) No later than August 15 preceding the rate year, each
hospital shall submit the OBRA form to the Department. Prior
to October 1, the Department shall notify each hospital
whether it has qualified as a Safety-Net Hospital.
(e) The Department may promulgate rules in order to
implement this Section.
(f) Nothing in this Section shall be construed as limiting
the ability of the Department to include the Safety-Net
Hospitals in the hospital rate reform mandated by Section
14-11 of this Code and implemented under Section 14-12 of this
Code and by administrative rulemaking.
(Source: P.A. 101-650, eff. 7-7-20; 101-669, eff. 4-2-21;
102-886, eff. 5-17-22.)
ARTICLE 45.
Section 45-5. The Hospital Licensing Act is amended by
changing Section 6.09 as follows:
(210 ILCS 85/6.09) (from Ch. 111 1/2, par. 147.09)

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Sec. 6.09. (a) In order to facilitate the orderly
transition of aged patients and patients with disabilities
from hospitals to post-hospital care, whenever a patient who
qualifies for the federal Medicare program is hospitalized,
the patient shall be notified of discharge at least 24 hours
prior to discharge from the hospital. With regard to pending
discharges to a skilled nursing facility, the hospital must
notify the case coordination unit, as defined in 89 Ill. Adm.
Code 240.260, at least 24 hours prior to discharge. When the
assessment is completed in the hospital, the case coordination
unit shall provide a copy of the required assessment
documentation directly to the nursing home to which the
patient is being discharged prior to discharge. The Department
on Aging shall provide notice of this requirement to case
coordination units. When a case coordination unit is unable to
complete an assessment in a hospital prior to the discharge of
a patient, 60 years of age or older, to a nursing home, the
case coordination unit shall notify the Department on Aging
which shall notify the Department of Healthcare and Family
Services. The Department on Aging shall adopt rules to address
these instances to ensure that the patient is able to access
nursing home care, the nursing home is not penalized for
accepting the admission, and the patient's timely discharge
from the hospital is not delayed, to the extent permitted
under federal law or regulation. Nothing in this subsection
shall preclude federal requirements for a pre-admission

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screening/mental health (PAS/MH) as required under Section
2-201.5 of the Nursing Home Care Act or State or federal law or
regulation. If home health services are ordered, the hospital
must inform its designated case coordination unit, as defined
in 89 Ill. Adm. Code 240.260, of the pending discharge and must
provide the patient with the case coordination unit's
telephone number and other contact information.
(b) Every hospital shall develop procedures for a
physician with medical staff privileges at the hospital or any
appropriate medical staff member to provide the discharge
notice prescribed in subsection (a) of this Section. The
procedures must include prohibitions against discharging or
referring a patient to any of the following if unlicensed,
uncertified, or unregistered: (i) a board and care facility,
as defined in the Board and Care Home Act; (ii) an assisted
living and shared housing establishment, as defined in the
Assisted Living and Shared Housing Act; (iii) a facility
licensed under the Nursing Home Care Act, the Specialized
Mental Health Rehabilitation Act of 2013, the ID/DD Community
Care Act, or the MC/DD Act; (iv) a supportive living facility,
as defined in Section 5-5.01a of the Illinois Public Aid Code;
or (v) a free-standing hospice facility licensed under the
Hospice Program Licensing Act if licensure, certification, or
registration is required. The Department of Public Health
shall annually provide hospitals with a list of licensed,
certified, or registered board and care facilities, assisted

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living and shared housing establishments, nursing homes,
supportive living facilities, facilities licensed under the
ID/DD Community Care Act, the MC/DD Act, or the Specialized
Mental Health Rehabilitation Act of 2013, and hospice
facilities. Reliance upon this list by a hospital shall
satisfy compliance with this requirement. The procedure may
also include a waiver for any case in which a discharge notice
is not feasible due to a short length of stay in the hospital
by the patient, or for any case in which the patient
voluntarily desires to leave the hospital before the
expiration of the 24 hour period.
(c) At least 24 hours prior to discharge from the
hospital, the patient shall receive written information on the
patient's right to appeal the discharge pursuant to the
federal Medicare program, including the steps to follow to
appeal the discharge and the appropriate telephone number to
call in case the patient intends to appeal the discharge.
(d) Before transfer of a patient to a long term care
facility licensed under the Nursing Home Care Act where
elderly persons reside, a hospital shall as soon as
practicable initiate a name-based criminal history background
check by electronic submission to the Illinois State Police
for all persons between the ages of 18 and 70 years; provided,
however, that a hospital shall be required to initiate such a
background check only with respect to patients who:
(1) are transferring to a long term care facility for

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the first time;
(2) have been in the hospital more than 5 days;
(3) are reasonably expected to remain at the long term
care facility for more than 30 days;
(4) have a known history of serious mental illness or
substance abuse; and
(5) are independently ambulatory or mobile for more
than a temporary period of time.
A hospital may also request a criminal history background
check for a patient who does not meet any of the criteria set
forth in items (1) through (5).
A hospital shall notify a long term care facility if the
hospital has initiated a criminal history background check on
a patient being discharged to that facility. In all
circumstances in which the hospital is required by this
subsection to initiate the criminal history background check,
the transfer to the long term care facility may proceed
regardless of the availability of criminal history results.
Upon receipt of the results, the hospital shall promptly
forward the results to the appropriate long term care
facility. If the results of the background check are
inconclusive, the hospital shall have no additional duty or
obligation to seek additional information from, or about, the
patient.
(Source: P.A. 102-538, eff. 8-20-21; 103-102, eff. 1-1-24.)

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ARTICLE 50.
Section 50-5. The Illinois Public Aid Code is amended by
changing Section 5-5.24 as follows:
(305 ILCS 5/5-5.24)
Sec. 5-5.24. Prenatal and perinatal care.
(a) The Department of Healthcare and Family Services may
provide reimbursement under this Article for all prenatal and
perinatal health care services that are provided for the
purpose of preventing low-birthweight infants, reducing the
need for neonatal intensive care hospital services, and
promoting perinatal and maternal health. These services may
include comprehensive risk assessments for pregnant
individuals, individuals with infants, and infants, lactation
counseling, nutrition counseling, childbirth support,
psychosocial counseling, treatment and prevention of
periodontal disease, language translation, nurse home
visitation, and other support services that have been proven
to improve birth and maternal health outcomes. The Department
shall maximize the use of preventive prenatal and perinatal
health care services consistent with federal statutes, rules,
and regulations. The Department of Public Aid (now Department
of Healthcare and Family Services) shall develop a plan for
prenatal and perinatal preventive health care and shall
present the plan to the General Assembly by January 1, 2004. On

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or before January 1, 2006 and every 2 years thereafter, the
Department shall report to the General Assembly concerning the
effectiveness of prenatal and perinatal health care services
reimbursed under this Section in preventing low-birthweight
infants and reducing the need for neonatal intensive care
hospital services. Each such report shall include an
evaluation of how the ratio of expenditures for treating
low-birthweight infants compared with the investment in
promoting healthy births and infants in local community areas
throughout Illinois relates to healthy infant development in
those areas.
On and after July 1, 2012, the Department shall reduce any
rate of reimbursement for services or other payments or alter
any methodologies authorized by this Code to reduce any rate
of reimbursement for services or other payments in accordance
with Section 5-5e.
(b)(1) As used in this subsection:
"Affiliated provider" means a provider who is enrolled in
the medical assistance program and has an active contract with
a managed care organization.
"Non-affiliated provider" means a provider who is enrolled
in the medical assistance program but does not have a contract
with an MCO.
"Preventive prenatal and perinatal health care services"
means services described in subsection (a) including the
following non-emergent diagnostic and ancillary services:

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(i) Diagnostic labs and imaging, including level II
ultrasounds.
(ii) RhoGAM injections.
(iii) Injectable 17-alpha-hydroxyprogesterone
caproate (commonly called 17P).
(iv) Intrapartum (labor and delivery) services.
(v) Any other outpatient or inpatient service relating
to pregnancy or the 12 months following childbirth or
fetal loss.
(2) In order to maximize the accessibility of preventive
prenatal and perinatal health care services, the Department of
Healthcare and Family Services shall amend its managed care
contracts such that an MCO must pay for preventive prenatal
services, perinatal healthcare services, and postpartum
services rendered by a non-affiliated provider, for which the
health plan would pay if rendered by an affiliated provider,
at the rate paid under the Illinois Medicaid fee-for-service
program methodology for such services, including all policy
adjusters, including, but not limited to, Medicaid High Volume
Adjustments, Medicaid Percentage Adjustments, Outpatient High
Volume Adjustments, and all outlier add-on adjustments to the
extent such adjustments are incorporated in the development of
the applicable MCO capitated rates, unless a different rate
was agreed upon by the health plan and the non-affiliated
provider.
(3) In cases where a managed care organization must pay

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for preventive prenatal services, perinatal healthcare
services, and postpartum services rendered by a non-affiliated
provider, the requirements under paragraph (2) shall not apply
if the services were not emergency services, as defined in
Section 5-30.1, and:
(A) the non-affiliated provider is a perinatal
hospital and has, within the 12 months preceding the date
of service, rejected a contract that was offered in good
faith by the health plan as determined by the Department;
or
(B) the health plan has terminated a contract with the
non-affiliated provider for cause, and the Department has
not deemed the termination to have been without merit. The
Department may deem that a determination for cause has
merit if:
(i) an institutional provider has repeatedly
failed to conduct discharge planning; or
(ii) the provider's conduct adversely and
substantially impacts the health of Medicaid patients;
or
(iii) the provider's conduct constitutes fraud,
waste, or abuse; or
(iv) the provider's conduct violates the code of
ethics governing his or her profession.
(4) For dates of service on and after January 1, 2026, the
medical assistance program shall provide coverage, without

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imposing a deductible, coinsurance, copayment, or any other
cost-sharing requirement, for preeclampsia biomarker testing
for predictive screening in asymptomatic individuals, or for
diagnosis and management when symptoms are present.
(Source: P.A. 102-665, eff. 10-8-21; 102-964, eff. 1-1-23.)
ARTICLE 55.
Section 55-5. The Specialized Mental Health Rehabilitation
Act of 2013 is amended by changing Sections 2-101 and 3-104 as
follows:
(210 ILCS 49/2-101)
Sec. 2-101. Standards for facilities.
(a) The Department shall, by rule, prescribe minimum
standards for each level of care for facilities to be in place
during the provisional licensure period and thereafter. These
standards shall include, but are not limited to, the
following:
(1) life safety standards that will ensure the health,
safety and welfare of residents and their protection from
hazards;
(2) number and qualifications of all personnel,
including management and clinical personnel, having
responsibility for any part of the care given to
consumers; specifically, the Department shall establish

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staffing ratios for facilities which shall specify the
number of staff hours per consumer of care that are needed
for each level of care offered within the facility;
(3) all sanitary conditions within the facility and
its surroundings, including water supply, sewage disposal,
food handling, and general hygiene which shall ensure the
health and comfort of consumers;
(4) a program for adequate maintenance of physical
plant and equipment;
(5) adequate accommodations, staff, and services for
the number and types of services being offered to
consumers for whom the facility is licensed to care;
(6) development of evacuation and other appropriate
safety plans for use during weather, health, fire,
physical plant, environmental, and national defense
emergencies;
(7) maintenance of minimum financial or other
resources necessary to meet the standards established
under this Section, and to operate and conduct the
facility in accordance with this Act;
(8) standards for coercive free environment,
restraint, and therapeutic separation; and
(9) each multiple bedroom shall have at least 55
square feet of net floor area per consumer, not including
space for closets, bathrooms, and clearly defined entryway
areas. A minimum of 3 feet of clearance at the foot and one

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side of each bed shall be provided.
(b) Any requirement contained in administrative rule
concerning a percentage of single occupancy rooms shall be
calculated based on the total number of licensed or
provisionally licensed beds under this Act on January 1, 2019
and shall not be calculated on a per-facility basis.
(c) A facility licensed under this Act shall not accept
any person experiencing an acute medical condition liable to
cause death, severe injury, or serious illness.
(Source: P.A. 101-10, eff. 6-5-19; 102-558, eff. 8-20-21.)
(210 ILCS 49/3-104)
Sec. 3-104. Care, treatment, and records. Facilities shall
provide, at a minimum, the following services: physician,
nursing, pharmaceutical, rehabilitative, and dietary services.
To provide these services, the facility shall adhere to the
following:
(1) Each consumer shall be encouraged and assisted to
achieve and maintain the highest level of self-care and
independence. Every effort shall be made to keep consumers
active and out of bed for reasonable periods of time,
except when contraindicated by physician orders.
(2) Every consumer shall be engaged in a
person-centered planning process regarding his or her
total care and treatment.
(3) All medical treatment and procedures shall be

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administered as ordered by a physician. All new physician
orders shall be reviewed by the facility's director of
nursing or charge nurse designee within 24 hours after
such orders have been issued to ensure facility compliance
with such orders. According to rules adopted by the
Department, every woman consumer of child bearing age
shall receive routine obstetrical and gynecological
evaluations as well as necessary prenatal care.
(4) Each consumer shall be provided with good
nutrition and with necessary fluids for hydration.
(5) Each consumer shall be provided visual privacy
during treatment and personal care.
(6) Every consumer or consumer's guardian shall be
permitted to inspect and copy all his or her clinical and
other records concerning his or her care kept by the
facility or by his or her physician. The facility may
charge a reasonable fee for duplication of a record.
(7) Each consumer shall be offered at least 15 hours
of treatment programming per week and shall be encouraged
to attend the treatment domains that meet the consumer's
needs, as reflected in the consumer's treatment plans.
Each consumer's program engagement and attendance shall be
documented in the consumer's clinical record, and each
consumer shall be prompted to attend programming regularly
as documented in the consumer's clinical record at least
quarterly.

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(Source: P.A. 98-104, eff. 7-22-13.)
ARTICLE 60.
Section 60-5. The Illinois Public Aid Code is amended by
adding Section 5-5.25a as follows:
(305 ILCS 5/5-5.25a new)
Sec. 5-5.25a. Coverage for seizure detection devices.
(a) As used in this Section, "seizure detection device"
means a monitoring device cleared by the United States Food
and Drug Administration, and any related technology,
application, service, or subscription supporting the
prescribed use of the device, that provides the following:
(1) individual monitoring and alert services relating
to seizure activity;
(2) detection or prediction of seizure activity and
transmission of notification of the seizure activity to
the individual or a caregiver for appropriate medical
response; or
(3) collection of data of the seizure activity of the
individual that can be used by a health care provider to
diagnose or appropriately treat a health care condition
that causes the seizure activity.
(b) All seizure detection devices covered under this
Section shall be approved for use by individuals, provided

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that the device has been prescribed and determined to be
medically necessary. The choice of device shall be made based
upon the individual's circumstances and medical needs in
consultation with the individual's medical provider.
(c) Any individual who has been prescribed a seizure
detection device shall not be required to obtain prior
authorization for coverage for a seizure detection device, and
coverage shall be continuous once the seizure detection device
is prescribed.
(d) Notwithstanding any other provision of this Section,
commencing July 1, 2027, all seizure detection devices cleared
by the United States Food and Drug Administration shall be
covered under the medical assistance program for persons who
have been prescribed a seizure detection device and who are
otherwise eligible for assistance under this Article.
(e) The Department shall not adopt rules or classification
policies that would limit the ability of individuals covered
by this Section to obtain seizure detection devices.
ARTICLE 65.
Section 65-5. The Community-Integrated Living Arrangements
Licensure and Certification Act is amended by changing Section
13.3 as follows:
(210 ILCS 135/13.3)

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Sec. 13.3. Community-integrated living arrangement per
diem reimbursement. As used in this Section, "medical absence"
means a situation in which a resident is temporarily absent
from a community-integrated living arrangement to receive
medical treatment or for other reasons that have been
recommended by third-party medical personnel, including, but
not limited to, hospitalizations, placements in short-term
stabilization homes or State-operated facilities, stays in
nursing facilities, rehabilitation in long-term care
facilities, or other absences for legitimate medical reasons.
Beginning January 1, 2025, the Department's Division of
Developmental Disabilities shall provide 100% of the per diem
reimbursement to a 24-hour community-integrated living
arrangement provider for up to 20 days for any resident
requiring a medical absence. During the medical absence, the
provider shall hold the bed for the resident. After the
medical absence, the resident shall return to the
community-integrated living arrangement when the resident is
medically able to return in order for the provider to receive
the full per diem reimbursement for the absent days. However,
if it is determined by a treating physician that the resident
is unable to return to the community-integrated living
arrangement, or if the resident dies during the medical
absence, the provider shall receive 100% of the per diem
reimbursement for up to 20 medical absence days. The per diem
reimbursement shall be in addition to the existing occupancy

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factor policy set by the Division of Developmental
Disabilities. Any Department policy or rulemaking issued to
implement this Section shall provide that for medical absences
a resident's termination date is the date the resident either
passes away or the date it is determined by a treating
physician that the resident is unable to return to the
community-integrated living arrangement.
(Source: P.A. 103-593, eff. 6-7-24.)
ARTICLE 75.
Section 75-5. The Illinois Public Aid Code is amended by
changing Section 5-5.02 as follows:
(305 ILCS 5/5-5.02) (from Ch. 23, par. 5-5.02)
Sec. 5-5.02. Hospital reimbursements.
(a) Reimbursement to hospitals; July 1, 1992 through
September 30, 1992. Notwithstanding any other provisions of
this Code or the Illinois Department's Rules promulgated under
the Illinois Administrative Procedure Act, reimbursement to
hospitals for services provided during the period July 1, 1992
through September 30, 1992, shall be as follows:
(1) For inpatient hospital services rendered, or if
applicable, for inpatient hospital discharges occurring,
on or after July 1, 1992 and on or before September 30,
1992, the Illinois Department shall reimburse hospitals

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for inpatient services under the reimbursement
methodologies in effect for each hospital, and at the
inpatient payment rate calculated for each hospital, as of
June 30, 1992. For purposes of this paragraph,
"reimbursement methodologies" means all reimbursement
methodologies that pertain to the provision of inpatient
hospital services, including, but not limited to, any
adjustments for disproportionate share, targeted access,
critical care access and uncompensated care, as defined by
the Illinois Department on June 30, 1992.
(2) For the purpose of calculating the inpatient
payment rate for each hospital eligible to receive
quarterly adjustment payments for targeted access and
critical care, as defined by the Illinois Department on
June 30, 1992, the adjustment payment for the period July
1, 1992 through September 30, 1992, shall be 25% of the
annual adjustment payments calculated for each eligible
hospital, as of June 30, 1992. The Illinois Department
shall determine by rule the adjustment payments for
targeted access and critical care beginning October 1,
1992.
(3) For the purpose of calculating the inpatient
payment rate for each hospital eligible to receive
quarterly adjustment payments for uncompensated care, as
defined by the Illinois Department on June 30, 1992, the
adjustment payment for the period August 1, 1992 through

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September 30, 1992, shall be one-sixth of the total
uncompensated care adjustment payments calculated for each
eligible hospital for the uncompensated care rate year, as
defined by the Illinois Department, ending on July 31,
1992. The Illinois Department shall determine by rule the
adjustment payments for uncompensated care beginning
October 1, 1992.
(b) Inpatient payments. For inpatient services provided on
or after October 1, 1993, in addition to rates paid for
hospital inpatient services pursuant to the Illinois Health
Finance Reform Act, as now or hereafter amended, or the
Illinois Department's prospective reimbursement methodology,
or any other methodology used by the Illinois Department for
inpatient services, the Illinois Department shall make
adjustment payments, in an amount calculated pursuant to the
methodology described in paragraph (c) of this Section, to
hospitals that the Illinois Department determines satisfy any
one of the following requirements:
(1) Hospitals that are described in Section 1923 of
the federal Social Security Act, as now or hereafter
amended, except that for rate year 2015 and after a
hospital described in Section 1923(b)(1)(B) of the federal
Social Security Act and qualified for the payments
described in subsection (c) of this Section for rate year
2014 provided the hospital continues to meet the
description in Section 1923(b)(1)(B) in the current

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determination year; or
(2) Illinois hospitals that have a Medicaid inpatient
utilization rate which is at least one-half a standard
deviation above the mean Medicaid inpatient utilization
rate for all hospitals in Illinois receiving Medicaid
payments from the Illinois Department; or
(3) Illinois hospitals that on July 1, 1991 had a
Medicaid inpatient utilization rate, as defined in
paragraph (h) of this Section, that was at least the mean
Medicaid inpatient utilization rate for all hospitals in
Illinois receiving Medicaid payments from the Illinois
Department and which were located in a planning area with
one-third or fewer excess beds as determined by the Health
Facilities and Services Review Board, and that, as of June
30, 1992, were located in a federally designated Health
Manpower Shortage Area; or
(4) Illinois hospitals that:
(A) have a Medicaid inpatient utilization rate
that is at least equal to the mean Medicaid inpatient
utilization rate for all hospitals in Illinois
receiving Medicaid payments from the Department; and
(B) also have a Medicaid obstetrical inpatient
utilization rate that is at least one standard
deviation above the mean Medicaid obstetrical
inpatient utilization rate for all hospitals in
Illinois receiving Medicaid payments from the

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Department for obstetrical services; or
(5) Any children's hospital, which means a hospital
devoted exclusively to caring for children. A hospital
which includes a facility devoted exclusively to caring
for children shall be considered a children's hospital to
the degree that the hospital's Medicaid care is provided
to children if either (i) the facility devoted exclusively
to caring for children is separately licensed as a
hospital by a municipality prior to February 28, 2013;
(ii) the hospital has been designated by the State as a
Level III perinatal care facility, has a Medicaid
Inpatient Utilization rate greater than 55% for the rate
year 2003 disproportionate share determination, and has
more than 10,000 qualified children days as defined by the
Department in rulemaking; (iii) the hospital has been
designated as a Perinatal Level III center by the State as
of December 1, 2017, is a Pediatric Critical Care Center
designated by the State as of December 1, 2017 and has a
2017 Medicaid inpatient utilization rate equal to or
greater than 45%; or (iv) the hospital has been designated
as a Perinatal Level II center by the State as of December
1, 2017, has a 2017 Medicaid Inpatient Utilization Rate
greater than 70%, and has at least 10 pediatric beds as
listed on the IDPH 2015 calendar year hospital profile; or
(6) A hospital that reopens a previously closed
hospital facility within 4 calendar years of the hospital

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facility's closure, if the previously closed hospital
facility qualified for payments under paragraph (c) at the
time of closure, until utilization data for the new
facility is available for the Medicaid inpatient
utilization rate calculation. For purposes of this clause,
a "closed hospital facility" shall include hospitals that
have been terminated from participation in the medical
assistance program in accordance with Section 12-4.25 of
this Code.
(c) Inpatient adjustment payments. The adjustment payments
required by paragraph (b) shall be calculated based upon the
hospital's Medicaid inpatient utilization rate as follows:
(1) hospitals with a Medicaid inpatient utilization
rate below the mean shall receive a per day adjustment
payment equal to $25;
(2) hospitals with a Medicaid inpatient utilization
rate that is equal to or greater than the mean Medicaid
inpatient utilization rate but less than one standard
deviation above the mean Medicaid inpatient utilization
rate shall receive a per day adjustment payment equal to
the sum of $25 plus $1 for each one percent that the
hospital's Medicaid inpatient utilization rate exceeds the
mean Medicaid inpatient utilization rate;
(3) hospitals with a Medicaid inpatient utilization
rate that is equal to or greater than one standard
deviation above the mean Medicaid inpatient utilization

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rate but less than 1.5 standard deviations above the mean
Medicaid inpatient utilization rate shall receive a per
day adjustment payment equal to the sum of $40 plus $7 for
each one percent that the hospital's Medicaid inpatient
utilization rate exceeds one standard deviation above the
mean Medicaid inpatient utilization rate;
(4) hospitals with a Medicaid inpatient utilization
rate that is equal to or greater than 1.5 standard
deviations above the mean Medicaid inpatient utilization
rate shall receive a per day adjustment payment equal to
the sum of $90 plus $2 for each one percent that the
hospital's Medicaid inpatient utilization rate exceeds 1.5
standard deviations above the mean Medicaid inpatient
utilization rate; and
(5) hospitals qualifying under clause (6) of paragraph
(b) shall have the rate assigned to the previously closed
hospital facility at the date of closure, until
utilization data for the new facility is available for the
Medicaid inpatient utilization rate calculation.
(c-1) Beginning October 1, 2026, for rate year 2027 and
thereafter, the Medicaid inpatient utilization rate used in
the determination of eligibility for payments under paragraph
(c) shall be modified to exclude from both the numerator and
denominator all days of care funded by the U.S. Department of
Veterans Affairs at a hospital approved to conduct its
operations from more than one location within contiguous

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counties under a single license, if at the time of its
licensing application the hospital was located in a county
with fewer than 125,000 inhabitants and the hospital's second
facility is located in a contiguous county with fewer than
235,000 inhabitants. For purposes of this subsection, days of
care funded by the U.S. Department of Veterans Affairs include
authorized VA community care provided at non-VA hospitals.
(d) Supplemental adjustment payments. In addition to the
adjustment payments described in paragraph (c), hospitals as
defined in clauses (1) through (6) of paragraph (b), excluding
county hospitals (as defined in subsection (c) of Section 15-1
of this Code) and a hospital organized under the University of
Illinois Hospital Act, shall be paid supplemental inpatient
adjustment payments of $60 per day. For purposes of Title XIX
of the federal Social Security Act, these supplemental
adjustment payments shall not be classified as adjustment
payments to disproportionate share hospitals.
(e) The inpatient adjustment payments described in
paragraphs (c) and (d) shall be increased on October 1, 1993
and annually thereafter by a percentage equal to the lesser of
(i) the increase in the DRI hospital cost index for the most
recent 12 month period for which data are available, or (ii)
the percentage increase in the statewide average hospital
payment rate over the previous year's statewide average
hospital payment rate. The sum of the inpatient adjustment
payments under paragraphs (c) and (d) to a hospital, other

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than a county hospital (as defined in subsection (c) of
Section 15-1 of this Code) or a hospital organized under the
University of Illinois Hospital Act, however, shall not exceed
$275 per day; that limit shall be increased on October 1, 1993
and annually thereafter by a percentage equal to the lesser of
(i) the increase in the DRI hospital cost index for the most
recent 12-month period for which data are available or (ii)
the percentage increase in the statewide average hospital
payment rate over the previous year's statewide average
hospital payment rate.
(f) Children's hospital inpatient adjustment payments. For
children's hospitals, as defined in clause (5) of paragraph
(b), the adjustment payments required pursuant to paragraphs
(c) and (d) shall be multiplied by 2.0.
(g) County hospital inpatient adjustment payments. For
county hospitals, as defined in subsection (c) of Section 15-1
of this Code, there shall be an adjustment payment as
determined by rules issued by the Illinois Department.
(h) For the purposes of this Section the following terms
shall be defined as follows:
(1) "Medicaid inpatient utilization rate" means a
fraction, the numerator of which is the number of a
hospital's inpatient days provided in a given 12-month
period to patients who, for such days, were eligible for
Medicaid under Title XIX of the federal Social Security
Act, and the denominator of which is the total number of

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the hospital's inpatient days in that same period.
(2) "Mean Medicaid inpatient utilization rate" means
the total number of Medicaid inpatient days provided by
all Illinois Medicaid-participating hospitals divided by
the total number of inpatient days provided by those same
hospitals.
(3) "Medicaid obstetrical inpatient utilization rate"
means the ratio of Medicaid obstetrical inpatient days to
total Medicaid inpatient days for all Illinois hospitals
receiving Medicaid payments from the Illinois Department.
(i) Inpatient adjustment payment limit. In order to meet
the limits of Public Law 102-234 and Public Law 103-66, the
Illinois Department shall by rule adjust disproportionate
share adjustment payments.
(j) University of Illinois Hospital inpatient adjustment
payments. For hospitals organized under the University of
Illinois Hospital Act, there shall be an adjustment payment as
determined by rules adopted by the Illinois Department.
(k) The Illinois Department may by rule establish criteria
for and develop methodologies for adjustment payments to
hospitals participating under this Article.
(l) On and after July 1, 2012, the Department shall reduce
any rate of reimbursement for services or other payments or
alter any methodologies authorized by this Code to reduce any
rate of reimbursement for services or other payments in
accordance with Section 5-5e.

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(m) The Department shall establish a cost-based
reimbursement methodology for determining payments to
hospitals for approved graduate medical education (GME)
programs for dates of service on and after July 1, 2018.
(1) As used in this subsection, "hospitals" means the
University of Illinois Hospital as defined in the
University of Illinois Hospital Act and a county hospital
in a county of over 3,000,000 inhabitants.
(2) An amendment to the Illinois Title XIX State Plan
defining GME shall maximize reimbursement, shall not be
limited to the education programs or special patient care
payments allowed under Medicare, and shall include:
(A) inpatient days;
(B) outpatient days;
(C) direct costs;
(D) indirect costs;
(E) managed care days;
(F) all stages of medical training and education
including students, interns, residents, and fellows
with no caps on the number of persons who may qualify;
and
(G) patient care payments related to the
complexities of treating Medicaid enrollees including
clinical and social determinants of health.
(3) The Department shall make all GME payments
directly to hospitals including such costs in support of

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clients enrolled in Medicaid managed care entities.
(4) The Department shall promptly take all actions
necessary for reimbursement to be effective for dates of
service on and after July 1, 2018 including publishing all
appropriate public notices, amendments to the Illinois
Title XIX State Plan, and adoption of administrative rules
if necessary.
(5) As used in this subsection, "managed care days"
means costs associated with services rendered to enrollees
of Medicaid managed care entities. "Medicaid managed care
entities" means any entity which contracts with the
Department to provide services paid for on a capitated
basis. "Medicaid managed care entities" includes a managed
care organization and a managed care community network.
(6) All payments under this Section are contingent
upon federal approval of changes to the Illinois Title XIX
State Plan, if that approval is required.
(7) The Department may adopt rules necessary to
implement Public Act 100-581 through the use of emergency
rulemaking in accordance with subsection (aa) of Section
5-45 of the Illinois Administrative Procedure Act. For
purposes of that Act, the General Assembly finds that the
adoption of rules to implement Public Act 100-581 is
deemed an emergency and necessary for the public interest,
safety, and welfare.
(Source: P.A. 101-81, eff. 7-12-19; 102-682, eff. 12-10-21;

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102-886, eff. 5-17-22.)
ARTICLE 85.
Section 85-5. The Illinois Act on the Aging is amended by
changing Section 4.02 as follows:
(20 ILCS 105/4.02)
Sec. 4.02. Community Care Program. The Department shall
establish a program of services to prevent unnecessary
institutionalization of persons age 60 and older in need of
long term care or who are established as persons who suffer
from Alzheimer's disease or a related disorder under the
Alzheimer's Disease Assistance Act, thereby enabling them to
remain in their own homes or in other living arrangements.
Such preventive services, which may be coordinated with other
programs for the aged, may include, but are not limited to, any
or all of the following:
(a) (blank);
(b) (blank);
(c) home care aide services;
(d) personal assistant services;
(e) adult day services;
(f) home-delivered meals;
(g) education in self-care;
(h) personal care services;

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(i) adult day health services;
(j) habilitation services;
(k) respite care;
(k-5) community reintegration services;
(k-6) flexible senior services;
(k-7) medication management;
(k-8) emergency home response;
(l) other nonmedical social services that may enable
the person to become self-supporting; or
(m) (blank).
The Department shall establish eligibility standards for
such services. In determining the amount and nature of
services for which a person may qualify, consideration shall
not be given to the value of cash, property, or other assets
held in the name of the person's spouse pursuant to a written
agreement dividing marital property into equal but separate
shares or pursuant to a transfer of the person's interest in a
home to his spouse, provided that the spouse's share of the
marital property is not made available to the person seeking
such services.
The Department shall require as a condition of eligibility
that all new financially eligible applicants apply for and
enroll in medical assistance under Article V of the Illinois
Public Aid Code in accordance with rules promulgated by the
Department.
The Department shall, in conjunction with the Department

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of Public Aid (now Department of Healthcare and Family
Services), seek appropriate amendments under Sections 1915 and
1924 of the Social Security Act. The purpose of the amendments
shall be to extend eligibility for home and community based
services under Sections 1915 and 1924 of the Social Security
Act to persons who transfer to or for the benefit of a spouse
those amounts of income and resources allowed under Section
1924 of the Social Security Act. Subject to the approval of
such amendments, the Department shall extend the provisions of
Section 5-4 of the Illinois Public Aid Code to persons who, but
for the provision of home or community-based services, would
require the level of care provided in an institution, as is
provided for in federal law. Those persons no longer found to
be eligible for receiving noninstitutional services due to
changes in the eligibility criteria shall be given 45 days
notice prior to actual termination. Those persons receiving
notice of termination may contact the Department and request
the determination be appealed at any time during the 45 day
notice period. The target population identified for the
purposes of this Section are persons age 60 and older with an
identified service need. Priority shall be given to those who
are at imminent risk of institutionalization. The services
shall be provided to eligible persons age 60 and older to the
extent that the cost of the services together with the other
personal maintenance expenses of the persons are reasonably
related to the standards established for care in a group

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facility appropriate to the person's condition. These
noninstitutional services, pilot projects, or experimental
facilities may be provided as part of or in addition to those
authorized by federal law or those funded and administered by
the Department of Human Services. The Departments of Human
Services, Healthcare and Family Services, Public Health,
Veterans' Affairs, and Commerce and Economic Opportunity and
other appropriate agencies of State, federal, and local
governments shall cooperate with the Department on Aging in
the establishment and development of the noninstitutional
services. The Department shall require an annual audit from
all personal assistant and home care aide vendors contracting
with the Department under this Section. The annual audit shall
assure that each audited vendor's procedures are in compliance
with Department's financial reporting guidelines requiring an
administrative and employee wage and benefits cost split as
defined in administrative rules. The audit is a public record
under the Freedom of Information Act. The Department shall
execute, relative to the nursing home prescreening project,
written inter-agency agreements with the Department of Human
Services and the Department of Healthcare and Family Services,
to effect the following: (1) intake procedures and common
eligibility criteria for those persons who are receiving
noninstitutional services; and (2) the establishment and
development of noninstitutional services in areas of the State
where they are not currently available or are undeveloped. On

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and after July 1, 1996, all nursing home prescreenings for
individuals 60 years of age or older shall be conducted by the
Department.
As part of the Department on Aging's routine training of
case managers and case manager supervisors, the Department may
include information on family futures planning for persons who
are age 60 or older and who are caregivers of their adult
children with developmental disabilities. The content of the
training shall be at the Department's discretion.
The Department is authorized to establish a system of
recipient copayment for services provided under this Section,
such copayment to be based upon the recipient's ability to pay
but in no case to exceed the actual cost of the services
provided. Additionally, any portion of a person's income which
is equal to or less than the federal poverty standard shall not
be considered by the Department in determining the copayment.
The level of such copayment shall be adjusted whenever
necessary to reflect any change in the officially designated
federal poverty standard.
The Department, or the Department's authorized
representative, may recover the amount of moneys expended for
services provided to or in behalf of a person under this
Section by a claim against the person's estate or against the
estate of the person's surviving spouse, but no recovery may
be had until after the death of the surviving spouse, if any,
and then only at such time when there is no surviving child who

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is under age 21 or blind or who has a permanent and total
disability. This paragraph, however, shall not bar recovery,
at the death of the person, of moneys for services provided to
the person or in behalf of the person under this Section to
which the person was not entitled; provided that such recovery
shall not be enforced against any real estate while it is
occupied as a homestead by the surviving spouse or other
dependent, if no claims by other creditors have been filed
against the estate, or, if such claims have been filed, they
remain dormant for failure of prosecution or failure of the
claimant to compel administration of the estate for the
purpose of payment. This paragraph shall not bar recovery from
the estate of a spouse, under Sections 1915 and 1924 of the
Social Security Act and Section 5-4 of the Illinois Public Aid
Code, who precedes a person receiving services under this
Section in death. All moneys for services paid to or in behalf
of the person under this Section shall be claimed for recovery
from the deceased spouse's estate. "Homestead", as used in
this paragraph, means the dwelling house and contiguous real
estate occupied by a surviving spouse or relative, as defined
by the rules and regulations of the Department of Healthcare
and Family Services, regardless of the value of the property.
The Department shall increase the effectiveness of the
existing Community Care Program by:
(1) ensuring that in-home services included in the
care plan are available on evenings and weekends;

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(2) ensuring that care plans contain the services that
eligible participants need based on the number of days in
a month, not limited to specific blocks of time, as
identified by the comprehensive assessment tool selected
by the Department for use statewide, not to exceed the
total monthly service cost maximum allowed for each
service; the Department shall develop administrative rules
to implement this item (2);
(3) ensuring that the participants have the right to
choose the services contained in their care plan and to
direct how those services are provided, based on
administrative rules established by the Department;
(4)(blank);
(5) ensuring that homemakers can provide personal care
services that may or may not involve contact with clients,
including, but not limited to:
(A) bathing;
(B) grooming;
(C) toileting;
(D) nail care;
(E) transferring;
(F) respiratory services;
(G) exercise; or
(H) positioning;
(6) ensuring that homemaker program vendors are not
restricted from hiring homemakers who are family members

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of clients or recommended by clients; the Department may
not, by rule or policy, require homemakers who are family
members of clients or recommended by clients to accept
assignments in homes other than the client;
(7) ensuring that the State may access maximum federal
matching funds by seeking approval for the Centers for
Medicare and Medicaid Services for modifications to the
State's home and community based services waiver and
additional waiver opportunities, including applying for
enrollment in the Balance Incentive Payment Program by May
1, 2013, in order to maximize federal matching funds; this
shall include, but not be limited to, modification that
reflects all changes in the Community Care Program
services and all increases in the services cost maximum;
(8) ensuring that the determination of need tool
accurately reflects the service needs of individuals with
Alzheimer's disease and related dementia disorders;
(9) ensuring that services are authorized accurately
and consistently for the Community Care Program (CCP); the
Department shall implement a Service Authorization policy
directive; the purpose shall be to ensure that eligibility
and services are authorized accurately and consistently in
the CCP program; the policy directive shall clarify
service authorization guidelines to Care Coordination
Units and Community Care Program providers no later than
May 1, 2013;

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(10) working in conjunction with Care Coordination
Units, the Department of Healthcare and Family Services,
the Department of Human Services, Community Care Program
providers, and other stakeholders to make improvements to
the Medicaid claiming processes and the Medicaid
enrollment procedures or requirements as needed,
including, but not limited to, specific policy changes or
rules to improve the up-front enrollment of participants
in the Medicaid program and specific policy changes or
rules to ensure insure more prompt submission of bills to
the federal government to secure maximum federal matching
dollars as promptly as possible; the Department on Aging
shall have at least 3 meetings with stakeholders by
January 1, 2014 in order to address these improvements;
(11) requiring home care service providers to comply
with the rounding of hours worked provisions under the
federal Fair Labor Standards Act (FLSA) and as set forth
in 29 CFR 785.48(b) by May 1, 2013;
(12) implementing any necessary policy changes or
promulgating any rules, no later than January 1, 2014, to
assist the Department of Healthcare and Family Services in
moving as many participants as possible, consistent with
federal regulations, into coordinated care plans if a care
coordination plan that covers long term care is available
in the recipient's area; and
(13) (blank).

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By January 1, 2009 or as soon after the end of the Cash and
Counseling Demonstration Project as is practicable, the
Department may, based on its evaluation of the demonstration
project, promulgate rules concerning personal assistant
services, to include, but need not be limited to,
qualifications, employment screening, rights under fair labor
standards, training, fiduciary agent, and supervision
requirements. All applicants shall be subject to the
provisions of the Health Care Worker Background Check Act.
The Department shall develop procedures to enhance
availability of services on evenings, weekends, and on an
emergency basis to meet the respite needs of caregivers.
Procedures shall be developed to permit the utilization of
services in successive blocks of 24 hours up to the monthly
maximum established by the Department. Workers providing these
services shall be appropriately trained.
No person may perform chore/housekeeping and home care
aide services under a program authorized by this Section
unless that person has been issued a certificate of
pre-service to do so by his or her employing agency.
Information gathered to effect such certification shall
include (i) the person's name, (ii) the date the person was
hired by his or her current employer, and (iii) the training,
including dates and levels. Persons engaged in the program
authorized by this Section before the effective date of this
amendatory Act of 1991 shall be issued a certificate of all

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pre-service and in-service training from his or her employer
upon submitting the necessary information. The employing
agency shall be required to retain records of all staff
pre-service and in-service training, and shall provide such
records to the Department upon request and upon termination of
the employer's contract with the Department. In addition, the
employing agency is responsible for the issuance of
certifications of in-service training completed to its their
employees.
The Department is required to develop a system to ensure
that persons working as home care aides and personal
assistants receive increases in their wages when the federal
minimum wage is increased by requiring vendors to certify that
they are meeting the federal minimum wage statute for home
care aides and personal assistants. An employer that cannot
ensure that the minimum wage increase is being given to home
care aides and personal assistants shall be denied any
increase in reimbursement costs.
The Community Care Program Advisory Committee is created
in the Department on Aging. The Director shall appoint
individuals to serve in the Committee, who shall serve at
their own expense. Members of the Committee must abide by all
applicable ethics laws. The Committee shall advise the
Department on issues related to the Department's program of
services to prevent unnecessary institutionalization. The
Committee shall meet on a bi-monthly basis and shall serve to

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identify and advise the Department on present and potential
issues affecting the service delivery network, the program's
clients, and the Department and to recommend solution
strategies. Persons appointed to the Committee shall be
appointed on, but not limited to, their own and their agency's
experience with the program, geographic representation, and
willingness to serve. The Director shall appoint members to
the Committee to represent provider, advocacy, policy
research, and other constituencies committed to the delivery
of high quality home and community-based services to older
adults. Representatives shall be appointed to ensure
representation from community care providers, including, but
not limited to, adult day service providers, homemaker
providers, case coordination and case management units,
emergency home response providers, statewide trade or labor
unions that represent home care aides and direct care staff,
area agencies on aging, adults over age 60, membership
organizations representing older adults, and other
organizational entities, providers of care, or individuals
with demonstrated interest and expertise in the field of home
and community care as determined by the Director.
Nominations may be presented from any agency or State
association with interest in the program. The Director, or his
or her designee, shall serve as the permanent co-chair of the
advisory committee. One other co-chair shall be nominated and
approved by the members of the committee on an annual basis.

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Committee members' terms of appointment shall be for 4 years
with one-quarter of the appointees' terms expiring each year.
A member shall continue to serve until his or her replacement
is named. The Department shall fill vacancies that have a
remaining term of over one year, and this replacement shall
occur through the annual replacement of expiring terms. The
Director shall designate Department staff to provide technical
assistance and staff support to the committee. Department
representation shall not constitute membership of the
committee. All Committee papers, issues, recommendations,
reports, and meeting memoranda are advisory only. The
Director, or his or her designee, shall make a written report,
as requested by the Committee, regarding issues before the
Committee.
The Department on Aging and the Department of Human
Services shall cooperate in the development and submission of
an annual report on programs and services provided under this
Section. Such joint report shall be filed with the Governor
and the General Assembly on or before March 31 of the following
fiscal year.
The requirement for reporting to the General Assembly
shall be satisfied by filing copies of the report as required
by Section 3.1 of the General Assembly Organization Act and
filing such additional copies with the State Government Report
Distribution Center for the General Assembly as is required
under paragraph (t) of Section 7 of the State Library Act.

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Those persons previously found eligible for receiving
noninstitutional services whose services were discontinued
under the Emergency Budget Act of Fiscal Year 1992, and who do
not meet the eligibility standards in effect on or after July
1, 1992, shall remain ineligible on and after July 1, 1992.
Those persons previously not required to cost-share and who
were required to cost-share effective March 1, 1992, shall
continue to meet cost-share requirements on and after July 1,
1992. Beginning July 1, 1992, all clients will be required to
meet eligibility, cost-share, and other requirements and will
have services discontinued or altered when they fail to meet
these requirements.
For the purposes of this Section, "flexible senior
services" refers to services that require one-time or periodic
expenditures, including, but not limited to, respite care,
home modification, assistive technology, housing assistance,
and transportation.
The Department shall implement an electronic service
verification based on global positioning systems or other
cost-effective technology for the Community Care Program no
later than January 1, 2014.
The Department shall require, as a condition of
eligibility, application for the medical assistance program
under Article V of the Illinois Public Aid Code.
The Department may authorize Community Care Program
services until an applicant is determined eligible for medical

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assistance under Article V of the Illinois Public Aid Code.
The Department shall continue to provide Community Care
Program reports as required by statute, which shall include an
annual report on Care Coordination Unit performance and
adherence to service guidelines and a 6-month supplemental
report.
In regard to community care providers, failure to comply
with Department on Aging policies shall be cause for
disciplinary action, including, but not limited to,
disqualification from serving Community Care Program clients.
Each provider, upon submission of any bill or invoice to the
Department for payment for services rendered, shall include a
notarized statement, under penalty of perjury pursuant to
Section 1-109 of the Code of Civil Procedure, that the
provider has complied with all Department policies.
The Director of the Department on Aging shall make
information available to the State Board of Elections as may
be required by an agreement the State Board of Elections has
entered into with a multi-state voter registration list
maintenance system.
The Department shall pay an enhanced rate of at least
$1.77 per unit under the Community Care Program to those
in-home service provider agencies that offer health insurance
coverage as a benefit to their direct service worker employees
pursuant to rules adopted by the Department. The Department
shall review the enhanced rate as part of its process to rebase

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in-home service provider reimbursement rates pursuant to
federal waiver requirements. Subject to federal approval,
beginning on January 1, 2024, rates for adult day services
shall be increased to $16.84 per hour and rates for each way
transportation services for adult day services shall be
increased to $12.44 per unit transportation.
Subject to federal approval, on and after January 1, 2024,
rates for homemaker services shall be increased to $28.07 to
sustain a minimum wage of $17 per hour for direct service
workers. Rates in subsequent State fiscal years shall be no
lower than the rates put into effect upon federal approval.
Providers of in-home services shall be required to certify to
the Department that they remain in compliance with the
mandated wage increase for direct service workers. Fringe
benefits, including, but not limited to, paid time off and
payment for training, health insurance, travel, or
transportation, shall not be reduced in relation to the rate
increases described in this paragraph.
Subject to and upon federal approval, on and after January
1, 2025, rates for homemaker services shall be increased to
$29.63 to sustain a minimum wage of $18 per hour for direct
service workers. Rates in subsequent State fiscal years shall
be no lower than the rates put into effect upon federal
approval. Providers of in-home services shall be required to
certify to the Department that they remain in compliance with
the mandated wage increase for direct service workers. Fringe

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benefits, including, but not limited to, paid time off and
payment for training, health insurance, travel, or
transportation, shall not be reduced in relation to the rate
increases described in this paragraph.
Subject to and upon federal approval, on and after January
1, 2026, rates for homemaker services shall be increased to
$30.80 to sustain a minimum wage of $18.75 per hour for direct
service workers. Rates in subsequent State fiscal years shall
be no lower than the rates put into effect upon federal
approval. Providers of in-home services shall be required to
certify to the Department that they remain in compliance with
the mandated wage increase for direct service workers. Fringe
benefits, including, but not limited to, paid time off and
payment for training, health insurance, travel, or
transportation, shall not be reduced in relation to the rate
increases described in this paragraph.
Beginning January 1, 2027, subject to any necessary
federal approval, rates for adult day services shall be
increased to $17.84 per hour and rates for each way
transportation services for adult day services shall be
increased to $13.44 per unit transportation.
The General Assembly finds it necessary to authorize an
aggressive Medicaid enrollment initiative designed to maximize
federal Medicaid funding for the Community Care Program which
produces significant savings for the State of Illinois. The
Department on Aging shall establish and implement a Community

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Care Program Medicaid Initiative. Under the Initiative, the
Department on Aging shall, at a minimum: (i) provide an
enhanced rate to adequately compensate care coordination units
to enroll eligible Community Care Program clients into
Medicaid; (ii) use recommendations from a stakeholder
committee on how best to implement the Initiative; and (iii)
establish requirements for State agencies to make enrollment
in the State's Medical Assistance program easier for seniors.
The Community Care Program Medicaid Enrollment Oversight
Subcommittee is created as a subcommittee of the Older Adult
Services Advisory Committee established in Section 35 of the
Older Adult Services Act to make recommendations on how best
to increase the number of medical assistance recipients who
are enrolled in the Community Care Program. The Subcommittee
shall consist of all of the following persons who must be
appointed within 30 days after June 4, 2018 (the effective
date of Public Act 100-587):
(1) The Director of Aging, or his or her designee, who
shall serve as the chairperson of the Subcommittee.
(2) One representative of the Department of Healthcare
and Family Services, appointed by the Director of
Healthcare and Family Services.
(3) One representative of the Department of Human
Services, appointed by the Secretary of Human Services.
(4) One individual representing a care coordination
unit, appointed by the Director of Aging.

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(5) One individual from a non-governmental statewide
organization that advocates for seniors, appointed by the
Director of Aging.
(6) One individual representing Area Agencies on
Aging, appointed by the Director of Aging.
(7) One individual from a statewide association
dedicated to Alzheimer's care, support, and research,
appointed by the Director of Aging.
(8) One individual from an organization that employs
persons who provide services under the Community Care
Program, appointed by the Director of Aging.
(9) One member of a trade or labor union representing
persons who provide services under the Community Care
Program, appointed by the Director of Aging.
(10) One member of the Senate, who shall serve as
co-chairperson, appointed by the President of the Senate.
(11) One member of the Senate, who shall serve as
co-chairperson, appointed by the Minority Leader of the
Senate.
(12) One member of the House of Representatives, who
shall serve as co-chairperson, appointed by the Speaker of
the House of Representatives.
(13) One member of the House of Representatives, who
shall serve as co-chairperson, appointed by the Minority
Leader of the House of Representatives.
(14) One individual appointed by a labor organization

10400SB3365ham001 - 208 - LRB104 18483 KTG 38682 a
representing frontline employees at the Department of
Human Services.
The Subcommittee shall provide oversight to the Community
Care Program Medicaid Initiative and shall meet quarterly. At
each Subcommittee meeting the Department on Aging shall
provide the following data sets to the Subcommittee: (A) the
number of Illinois residents, categorized by planning and
service area, who are receiving services under the Community
Care Program and are enrolled in the State's Medical
Assistance Program; (B) the number of Illinois residents,
categorized by planning and service area, who are receiving
services under the Community Care Program, but are not
enrolled in the State's Medical Assistance Program; and (C)
the number of Illinois residents, categorized by planning and
service area, who are receiving services under the Community
Care Program and are eligible for benefits under the State's
Medical Assistance Program, but are not enrolled in the
State's Medical Assistance Program. In addition to this data,
the Department on Aging shall provide the Subcommittee with
plans on how the Department on Aging will reduce the number of
Illinois residents who are not enrolled in the State's Medical
Assistance Program but who are eligible for medical assistance
benefits. The Department on Aging shall enroll in the State's
Medical Assistance Program those Illinois residents who
receive services under the Community Care Program and are
eligible for medical assistance benefits but are not enrolled

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in the State's Medical Medicaid Assistance Program. The data
provided to the Subcommittee shall be made available to the
public via the Department on Aging's website.
The Department on Aging, with the involvement of the
Subcommittee, shall collaborate with the Department of Human
Services and the Department of Healthcare and Family Services
on how best to achieve the responsibilities of the Community
Care Program Medicaid Initiative.
The Department on Aging, the Department of Human Services,
and the Department of Healthcare and Family Services shall
coordinate and implement a streamlined process for seniors to
access benefits under the State's Medical Assistance Program.
The Subcommittee shall collaborate with the Department of
Human Services on the adoption of a uniform application
submission process. The Department of Human Services and any
other State agency involved with processing the medical
assistance application of any person enrolled in the Community
Care Program shall include the appropriate care coordination
unit in all communications related to the determination or
status of the application.
The Community Care Program Medicaid Initiative shall
provide targeted funding to care coordination units to help
seniors complete their applications for medical assistance
benefits. On and after July 1, 2019, care coordination units
shall receive no less than $200 per completed application,
which rate may be included in a bundled rate for initial intake

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services when Medicaid application assistance is provided in
conjunction with the initial intake process for new program
participants.
The Community Care Program Medicaid Initiative shall cease
operation 5 years after June 4, 2018 (the effective date of
Public Act 100-587), after which the Subcommittee shall
dissolve.
Effective July 1, 2023, subject to federal approval, the
Department on Aging shall reimburse Care Coordination Units at
the following rates for case management services: $252.40 for
each initial assessment; $366.40 for each initial assessment
with translation; $229.68 for each redetermination assessment;
$313.68 for each redetermination assessment with translation;
$200.00 for each completed application for medical assistance
benefits; $132.26 for each face-to-face, choices-for-care
screening; $168.26 for each face-to-face, choices-for-care
screening with translation; $124.56 for each 6-month,
face-to-face visit; $132.00 for each MCO participant
eligibility determination; and $157.00 for each MCO
participant eligibility determination with translation.
(Source: P.A. 103-8, eff. 6-7-23; 103-102, Article 45, Section
45-5, eff. 1-1-24; 103-102, Article 85, Section 85-5, eff.
1-1-24; 103-102, Article 90, Section 90-5, eff. 1-1-24;
103-588, eff. 6-5-24; 103-605, eff. 7-1-24; 103-670, eff.
1-1-25; 104-2, eff. 6-16-25; 104-417, eff. 8-15-25.)

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ARTICLE 145.
Section 145-5. The Illinois Public Aid Code is amended by
changing Section 14-12.5 as follows:
(305 ILCS 5/14-12.5)
Sec. 14-12.5. Hospital rate updates.
(a) Notwithstanding any other provision of this Code, the
hospital rates of reimbursement authorized under Sections
5-5.05, 14-12, and 14-13 of this Code shall be adjusted in
accordance with the provisions of this Section.
(b) Notwithstanding any other provision of this Code,
effective for dates of service on and after January 1, 2024,
subject to federal approval, hospital reimbursement rates
shall be revised as follows:
(1) For inpatient general acute care services, the
statewide-standardized amount and the per diem rates for
hospitals exempt from the APR-DRG reimbursement system, in
effect January 1, 2023, shall be increased by 10%.
(2) For inpatient psychiatric services:
(A) For safety-net hospitals, the hospital
specific per diem rate in effect January 1, 2023 and
the minimum per diem rate of $630, authorized in
subsection (b-5) of Section 5-5.05 of this Code, shall
be increased by 10%.
(B) For all general acute care hospitals that are

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not safety-net hospitals, the inpatient psychiatric
care per diem rates in effect January 1, 2023 shall be
increased by 10%, except that all rates shall be at
least 90% of the minimum inpatient psychiatric care
per diem rate for safety-net hospitals as authorized
in subsection (b-5) of Section 5-5.05 of this Code
including the adjustments authorized in this Section.
The statewide default per diem rate for a hospital
opening a new psychiatric distinct part unit, shall be
set at 90% of the minimum inpatient psychiatric care
per diem rate for safety-net hospitals as authorized
in subsection (b-5) of Section 5-5.05 of this Code,
including the adjustment authorized in this Section.
(C) For all psychiatric specialty hospitals, the
per diem rates in effect January 1, 2023, shall be
increased by 10%, except that all rates shall be at
least 90% of the minimum inpatient per diem rate for
safety-net hospitals as authorized in subsection (b-5)
of Section 5-5.05 of this Code, including the
adjustments authorized in this Section. The statewide
default per diem rate for a new psychiatric specialty
hospital shall be set at 90% of the minimum inpatient
psychiatric care per diem rate for safety-net
hospitals as authorized in subsection (b-5) of Section
5-5.05 of this Code, including the adjustment
authorized in this Section.

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(3) For inpatient rehabilitative services, all
hospital specific per diem rates in effect January 1,
2023, shall be increased by 10%. The statewide default
inpatient rehabilitative services per diem rates, for
general acute care hospitals and for rehabilitation
specialty hospitals respectively, shall be increased by
10%.
(4) The statewide-standardized amount for outpatient
general acute care services in effect January 1, 2023,
shall be increased by 10%.
(5) The statewide-standardized amount for outpatient
psychiatric care services in effect January 1, 2023, shall
be increased by 10%.
(6) The statewide-standardized amount for outpatient
rehabilitative care services in effect January 1, 2023,
shall be increased by 10%.
(7) The per diem rate in effect January 1, 2023, as
authorized in subsection (a) of Section 14-13 of this
Article shall be increased by 10%.
(8) For services provided on and after January 1, 2024
through June 30, 2024, and on and after January 1, 2029
2027, subject to federal approval, in addition to the
statewide standardized amount, an add-on payment of at
least $210 shall be paid for each inpatient General Acute
and Psychiatric day of care, excluding Medicare-Medicaid
dual eligible crossover days, for all safety-net hospitals

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defined in Section 5-5e.1 of this Code.
(A) For Psychiatric days of care, the Department
may implement payment of this add-on by increasing the
hospital specific psychiatric per diem rate, adjusted
in accordance with subparagraph (A) of paragraph (2)
of subsection (b) by $210, or by a separate add-on
payment.
(B) If the add-on adjustment is added to the
hospital specific psychiatric per diem rate to
operationalize payment, the Department shall provide a
rate sheet to each safety-net hospital, which
identifies the hospital psychiatric per diem rate
before and after the adjustment.
(C) The add-on adjustment shall not be considered
when setting the 90% minimum rate identified in
paragraph (2) of subsection (b).
(9) For services provided on and after July 1, 2024,
and on or before December 31, 2028 2026, subject to
federal approval, in addition to the statewide
standardized amount and any other payments authorized
under this Code, a safety-net hospital health care equity
add-on payment shall be paid for each inpatient General
Acute and Psychiatric day of care, excluding
Medicare-Medicaid dual eligible crossover days, for
safety-net hospitals defined in Section 5-5e.1 of this
Code, as follows:

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(A) if the safety-net hospital's Medicaid
inpatient utilization rate, as calculated under
Section 5-5e.1 of this Code, is equal to or greater
than 70%, the add-on payment shall be $425;
(B) if the safety-net hospital's Medicaid
inpatient utilization rate, as calculated under
Section 5-5e.1 of this Code, is equal to or greater
than 50% and less than 70%, the add-on payment shall be
$300;
(C) if the safety-net hospital's Medicaid
inpatient utilization rate, as calculated under
Section 5-5e.1 of this Code, is equal to or greater
than 40% and less than 50%, the add-on payment shall be
$225; and
(D) if the safety-net hospital's Medicaid
inpatient utilization rate, as calculated under
Section 5-5e.1 of this Code, is less than 40%, the
add-on payment shall be $210.
Qualification for the safety-net hospital health care
equity add-on payment shall be updated January 1, 2026,
and each January 1 thereafter based on the MIUR
determination effective 3 months prior to the start of
each the January 1, 2026 calendar year, ending in 2028.
Rates described in subparagraphs (A) through (C) shall
be adjusted annually beginning January 1, 2026 by applying
a uniform factor to each rate to spend an approximate

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amount of $50,000,000 annually per year using State fiscal
year 2024 days as a basis for calendar year 2026 rates.
The add-on adjustment under this paragraph shall not
be considered when setting the 90% minimum rate identified
in subparagraph (B) of paragraph (2).
(10) For services provided on and after July 1, 2024,
and on or before December 31, 2028 2026, subject to
federal approval, in addition to the statewide
standardized amount and any other payments authorized
under this Code, a safety-net hospital low volume add-on
payment of the lesser of $200 or the annually recalculated
amount described below shall be paid for each inpatient
General Acute and Psychiatric day of care, excluding
Medicare-Medicaid dual eligible crossover days, for any
safety-net hospital as defined in Section 5-5e.1 that
provided less than 11,000 Medicaid inpatient days of care,
excluding Medicare-Medicaid dual eligible crossover days,
in the base period. As used in this paragraph, "base
period" means State fiscal year 2022 admissions received
by the Department prior to October 1, 2023 for the payment
period July 1, 2024 through December 31, 2025, and
beginning in calendar year 2026, the State fiscal year
that ends 30 months before the applicable calendar year,
such as State fiscal year 2023 admissions received by the
Department prior to October 1, 2024, for calendar year
2026. The low volume add-on payment amount of $200 shall

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be adjusted annually beginning January 1, 2027 if
projected overall payment exceeds $30,000,000 by setting a
rate to spend an approximate amount of $30,000,000
annually using the most recent complete State fiscal year
inpatient General Acute and Psychiatric day of care data,
excluding Medicare-Medicaid dual eligible crossover days
for qualifying hospitals. State Fiscal Year 2025 data
shall be used as the basis for the Calendar Year 2027 rate,
and State Fiscal Year 2026 data shall be used as the basis
for the Calendar Year 2028 rate.
(c) The Department shall take all actions necessary to
ensure the changes authorized in Public Act 103-102 and this
amendatory Act of the 103rd General Assembly are in effect for
dates of service on and after the effective date of the changes
made to this Section by this amendatory Act of the 103rd
General Assembly, including publishing all appropriate public
notices, applying for federal approval of amendments to the
Illinois Title XIX State Plan, and adopting administrative
rules if necessary.
(d) The Department of Healthcare and Family Services may
adopt rules necessary to implement the changes made by Public
Act 103-102 and this amendatory Act of the 103rd General
Assembly through the use of emergency rulemaking in accordance
with Section 5-45 of the Illinois Administrative Procedure
Act. The 24-month limitation on the adoption of emergency
rules does not apply to rules adopted under this Section. The

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General Assembly finds that the adoption of rules to implement
the changes made by Public Act 103-102 and this amendatory Act
of the 103rd General Assembly is deemed an emergency and
necessary for the public interest, safety, and welfare.
(e) The Department shall ensure that all necessary
adjustments to the managed care organization capitation base
rates necessitated by the adjustments in this Section are
completed, published, and applied in accordance with Section
5-30.8 of this Code 90 days prior to the implementation date of
the changes required under Public Act 103-102 and this
amendatory Act of the 103rd General Assembly.
(f) The Department shall publish updated rate sheets or
add-on payment amounts, as applicable, for all hospitals 30
days prior to the effective date of the rate increase, or
within 30 days after federal approval by the Centers for
Medicare and Medicaid Services, whichever is later.
(Source: P.A. 103-102, eff. 6-16-23; 103-593, eff. 6-7-24.)
ARTICLE 170.
Section 170-5. The Illinois Public Aid Code is amended by
changing Section 1-8.5 as follows:
(305 ILCS 5/1-8.5)
Sec. 1-8.5. Eligibility for medical assistance during
periods of incarceration or detention.

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(a) To the extent permitted by federal law and
notwithstanding any other provision of this Code, the
Department of Healthcare and Family Services shall not cancel
a person's eligibility for medical assistance, nor shall the
Department deny a person's application for medical assistance,
solely because that person has become or is an inmate of a
public institution, including, but not limited to, a county
jail, juvenile detention center, or State correctional
facility. The person may be and remain enrolled for medical
assistance as long as all other eligibility criteria are met.
(b) The Department may adopt rules to permit a person to
apply for medical assistance while he or she is an inmate of a
public institution as described in subsection (a). The rules
may limit applications to persons who would be likely to
qualify for medical assistance if they resided in the
community. Any such person who is not already enrolled for
medical assistance may apply for medical assistance prior to
the date of scheduled release or discharge from a penal
institution or county jail or similar status.
(c) Except as provided under Section 17 of the County Jail
Act, the Department shall not be responsible to provide
medical assistance under this Code for any medical care,
services, or supplies provided to a person while he or she is
an inmate of a public institution as described in subsection
(a). The responsibility for providing medical care shall
remain as otherwise provided by law with the Department of

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Corrections, county, or other arresting authority. The
Department may seek federal financial participation, to the
extent that it is available and with the cooperation of the
Department of Juvenile Justice, the Department of Corrections,
or the relevant county, for the costs of those services.
(c-1) Notwithstanding subsection (c), the Department may
provide medical assistance under this Code for medical care,
services, and supplies provided to a person while he or she is
an inmate of a public institution as described in subsection
(a) to the extent authorized under a federally approved 1115
Waiver or other federal authority. The medical care, services,
and supplies covered, and any other standards, limitations, or
conditions for coverage, shall be established by rule by the
Department in accordance with the federal authority obtained.
(d) To the extent permitted under State and federal law,
the Department shall develop procedures to expedite required
periodic reviews of continued eligibility for persons
described in subsection (a).
(e) Counties, the Department of Juvenile Justice, the
Department of Human Services, and the Department of
Corrections shall cooperate with the Department in
administering this Section. That cooperation shall include
managing eligibility processing and sharing information
sufficient to inform the Department, in a manner established
by the Department, that a person enrolled in the medical
assistance program has been detained or incarcerated.

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(f) The Department shall resume responsibility for
providing medical assistance upon release of the person to the
community as long as all of the following apply:
(1) The person is enrolled for medical assistance at
the time of release.
(2) Neither a county, the Department of Juvenile
Justice, the Department of Corrections, nor any other
criminal justice authority continues to bear
responsibility for the person's medical care.
(3) The county, the Department of Juvenile Justice, or
the Department of Corrections provides timely notice of
the date of release in a manner established by the
Department.
(g) This Section applies on and after December 31, 2011.
(Source: P.A. 98-139, eff. 1-1-14; 99-415, eff. 8-20-15.)
ARTICLE 175.
Section 175-5. The Illinois Public Aid Code is amended by
changing Section 5-30.1 as follows:
(305 ILCS 5/5-30.1)
Sec. 5-30.1. Managed care protections.
(a) As used in this Section:
"Managed care organization" or "MCO" means any entity
which contracts with the Department to provide services where

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payment for medical services is made on a capitated basis.
"Emergency services" means health care items and services,
including inpatient and outpatient hospital services,
furnished or required to evaluate and stabilize an emergency
medical condition. "Emergency services" include inpatient
stabilization services furnished during the inpatient
stabilization period. "Emergency services" do not include
post-stabilization medical services.
"Emergency medical condition" means a medical condition
manifesting itself by acute symptoms of sufficient severity,
regardless of the final diagnosis given, such that a prudent
layperson, who possesses an average knowledge of health and
medicine, could reasonably expect the absence of immediate
medical attention to result in:
(1) placing the health of the individual (or, with
respect to a pregnant woman, the health of the woman or her
unborn child) in serious jeopardy;
(2) serious impairment to bodily functions;
(3) serious dysfunction of any bodily organ or part;
(4) inadequately controlled pain; or
(5) with respect to a pregnant woman who is having
contractions:
(A) inadequate time to complete a safe transfer to
another hospital before delivery; or
(B) a transfer to another hospital may pose a
threat to the health or safety of the woman or unborn

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child.
"Emergency medical screening examination" means a medical
screening examination and evaluation by a physician licensed
to practice medicine in all its branches or, to the extent
permitted by applicable laws, by other appropriately licensed
personnel under the supervision of or in collaboration with a
physician licensed to practice medicine in all its branches to
determine whether the need for emergency services exists.
"Health care services" means mean any medical or
behavioral health services covered under the medical
assistance program that are subject to review under a service
authorization program.
"Inpatient stabilization period" means the initial 72
hours of inpatient stabilization services, beginning from the
date and time of the order for inpatient admission to the
hospital.
"Inpatient stabilization services" means mean emergency
services furnished in the inpatient setting at a hospital
pursuant to an order for inpatient admission by a physician or
other qualified practitioner who has admitting privileges at
the hospital, as permitted by State law, to stabilize an
emergency medical condition following an emergency medical
screening examination.
"Post-stabilization medical services" means health care
services provided to an enrollee that are furnished in a
hospital by a provider that is qualified to furnish such

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services and determined to be medically necessary by the
provider and directly related to the emergency medical
condition following stabilization.
"Provider" means a facility or individual who is actively
enrolled in the medical assistance program and licensed or
otherwise authorized to order, prescribe, refer, or render
health care services in this State.
"Service authorization determination" means a decision
made by a service authorization program in advance of,
concurrent to, or after the provision of a health care service
to approve, change the level of care, partially deny, deny, or
otherwise limit coverage and reimbursement for a health care
service upon review of a service authorization request.
"Service authorization program" means any utilization
review, utilization management, peer review, quality review,
or other medical management activity conducted by an MCO, or
its contracted utilization review organization, including, but
not limited to, prior authorization, prior approval,
pre-certification, concurrent review, retrospective review, or
certification of admission, of health care services provided
in the inpatient or outpatient hospital setting.
"Service authorization request" means a request by a
provider to a service authorization program to determine
whether a health care service meets the reimbursement
eligibility requirements for medically necessary, clinically
appropriate care, resulting in the issuance of a service

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authorization determination.
"Utilization review organization" or "URO" means an MCO's
utilization review department or a peer review organization or
quality improvement organization that contracts with an MCO to
administer a service authorization program and make service
authorization determinations.
(b) As provided by Section 5-16.12, managed care
organizations are subject to the provisions of the Managed
Care Reform and Patient Rights Act.
(c) An MCO shall pay any provider of emergency services,
including for inpatient stabilization services provided during
the inpatient stabilization period, that does not have in
effect a contract with the contracted Medicaid MCO. The
default rate of reimbursement shall be the rate paid under
Illinois Medicaid fee-for-service program methodology,
including all policy adjusters, including but not limited to
Medicaid High Volume Adjustments, Medicaid Percentage
Adjustments, Outpatient High Volume Adjustments, and all
outlier add-on adjustments to the extent such adjustments are
incorporated in the development of the applicable MCO
capitated rates.
(d) (Blank).
(e) Notwithstanding any other provision of law, the
following requirements apply to MCOs in determining payment
for all emergency services, including inpatient stabilization
services provided during the inpatient stabilization period:

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(1) The MCO shall not impose any service authorization
program requirements for emergency services, including,
but not limited to, prior authorization, prior approval,
pre-certification, certification of admission, concurrent
review, or retrospective review.
(A) Notification period: Hospitals shall notify
the enrollee's Medicaid MCO within 48 hours of the
date and time the order for inpatient admission is
written. Notification shall be limited to advising the
MCO that the patient has been admitted to a hospital
inpatient level of care.
(B) If the admitting hospital complies with the
notification provisions of subparagraph (A), the
Medicaid MCO may not initiate concurrent review before
the end of the inpatient stabilization period. If the
admitting hospital does not comply with the
notification requirements in subparagraph (A), the
Medicaid MCO may initiate concurrent review for the
continuation of the stay beginning at the end of the
48-hour notification period.
(C) Coverage for services provided during the
48-hour notification period may not be retrospectively
denied.
(2) The MCO shall cover emergency services provided to
enrollees who are temporarily away from their residence
and outside the contracting area to the extent that the

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enrollees would be entitled to the emergency services if
they still were within the contracting area.
(3) The MCO shall have no obligation to cover
emergency services provided on an emergency basis that are
not covered services under the contract between the MCO
and the Department.
(4) The MCO shall not condition coverage for emergency
services on the treating provider notifying the MCO of the
enrollee's emergency medical screening examination and
treatment within 10 days after presentation for emergency
services.
(5) The determination of the attending emergency
physician, or the practitioner responsible for the
enrollee's care at the hospital, of whether an enrollee
requires inpatient stabilization services, can be
stabilized in the outpatient setting, or is sufficiently
stabilized for discharge or transfer to another setting,
shall be binding on the MCO. The MCO shall cover and
reimburse providers for emergency services as billed by
the provider for all enrollees whether the emergency
services are provided by an affiliated or non-affiliated
provider, except in cases of fraud. The MCO shall
reimburse inpatient stabilization services provided during
the inpatient stabilization period and billed as inpatient
level of care based on the appropriate inpatient
reimbursement methodology.

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(6) The MCO's financial responsibility for
post-stabilization medical services it has not
pre-approved ends when:
(A) a plan physician with privileges at the
treating hospital assumes responsibility for the
enrollee's care;
(B) a plan physician assumes responsibility for
the enrollee's care through transfer;
(C) a contracting entity representative and the
treating physician reach an agreement concerning the
enrollee's care; or
(D) the enrollee is discharged.
(e-5) An MCO shall pay for all post-stabilization medical
services as a covered service in any of the following
situations:
(1) the MCO or its URO authorized such services;
(2) such services were administered to maintain the
enrollee's stabilized condition within one hour after a
request to the MCO for authorization of further
post-stabilization services;
(3) the MCO or its URO did not respond to a request to
authorize such services within one hour;
(4) the MCO or its URO could not be contacted; or
(5) the MCO or its URO and the treating provider, if
the treating provider is a non-affiliated provider, could
not reach an agreement concerning the enrollee's care and

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an affiliated provider was unavailable for a consultation,
in which case the MCO must pay for such services rendered
by the treating non-affiliated provider until an
affiliated provider was reached and either concurred with
the treating non-affiliated provider's plan of care or
assumed responsibility for the enrollee's care. Such
payment shall be made at the default rate of reimbursement
paid under the State's Medicaid fee-for-service program
methodology, including all policy adjusters, including,
but not limited to, Medicaid High Volume Adjustments,
Medicaid Percentage Adjustments, Outpatient High Volume
Adjustments, and all outlier add-on adjustments to the
extent that such adjustments are incorporated in the
development of the applicable MCO capitated rates.
(f) Network adequacy and transparency.
(1) The Department shall:
(A) ensure that an adequate provider network is in
place, taking into consideration health professional
shortage areas and medically underserved areas;
(B) publicly release an explanation of its process
for analyzing network adequacy;
(C) periodically ensure that an MCO continues to
have an adequate network in place;
(D) require MCOs, including Medicaid Managed Care
Entities as defined in Section 5-30.2, to meet
provider directory requirements under Section 5-30.3;

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(E) require MCOs to ensure that any
Medicaid-certified provider under contract with an MCO
and previously submitted on a roster on the date of
service is paid for any medically necessary,
Medicaid-covered, and authorized service rendered to
any of the MCO's enrollees, regardless of inclusion on
the MCO's published and publicly available directory
of available providers; and
(F) require MCOs, including Medicaid Managed Care
Entities as defined in Section 5-30.2, to meet each of
the requirements under subsection (d-5) of Section 10
of the Network Adequacy and Transparency Act; with
necessary exceptions to the MCO's network to ensure
that admission and treatment with a provider or at a
treatment facility in accordance with the network
adequacy standards in paragraph (3) of subsection
(d-5) of Section 10 of the Network Adequacy and
Transparency Act is limited to providers or facilities
that are Medicaid certified.
(2) Each MCO shall confirm its receipt of information
submitted specific to physician or dentist additions or
physician or dentist deletions from the MCO's provider
network within 3 days after receiving all required
information from contracted physicians or dentists, and
electronic physician and dental directories must be
updated consistent with current rules as published by the

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Centers for Medicare and Medicaid Services or its
successor agency.
(g) Timely payment of claims.
(1) The MCO shall pay a claim within 30 days of
receiving a claim that contains all the essential
information needed to adjudicate the claim.
(2) The MCO shall notify the billing party of its
inability to adjudicate a claim within 30 days of
receiving that claim.
(3) The MCO shall pay a penalty that is at least equal
to the timely payment interest penalty imposed under
Section 368a of the Illinois Insurance Code for any claims
not timely paid.
(A) When an MCO is required to pay a timely payment
interest penalty to a provider, the MCO must calculate
and pay the timely payment interest penalty that is
due to the provider within 30 days after the payment of
the claim. In no event shall a provider be required to
request or apply for payment of any owed timely
payment interest penalties.
(B) Such payments shall be reported separately
from the claim payment for services rendered to the
MCO's enrollee and clearly identified as interest
payments.
(4)(A) The Department shall require MCOs to expedite
payments to providers identified on the Department's

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expedited provider list, determined in accordance with 89
Ill. Adm. Code 140.71(b), on a schedule at least as
frequently as the providers are paid under the
Department's fee-for-service expedited provider schedule.
(B) Compliance with the expedited provider requirement
may be satisfied by an MCO through the use of a Periodic
Interim Payment (PIP) program that has been mutually
agreed to and documented between the MCO and the provider,
if the PIP program ensures that any expedited provider
receives regular and periodic payments based on prior
period payment experience from that MCO. Total payments
under the PIP program may be reconciled against future PIP
payments on a schedule mutually agreed to between the MCO
and the provider.
(C) The Department shall share at least monthly its
expedited provider list and the frequency with which it
pays providers on the expedited list.
(g-5) Recognizing that the rapid transformation of the
Illinois Medicaid program may have unintended operational
challenges for both payers and providers:
(1) in no instance shall a medically necessary covered
service rendered in good faith, based upon eligibility
information documented by the provider, be denied coverage
or diminished in payment amount if the eligibility or
coverage information available at the time the service was
rendered is later found to be inaccurate in the assignment

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of coverage responsibility between MCOs or the
fee-for-service system, except for instances when an
individual is deemed to have not been eligible for
coverage under the Illinois Medicaid program; and
(2) the Department shall, by December 31, 2016, adopt
rules establishing policies that shall be included in the
Medicaid managed care policy and procedures manual
addressing payment resolutions in situations in which a
provider renders services based upon information obtained
after verifying a patient's eligibility and coverage plan
through either the Department's current enrollment system
or a system operated by the coverage plan identified by
the patient presenting for services:
(A) such medically necessary covered services
shall be considered rendered in good faith;
(B) such policies and procedures shall be
developed in consultation with industry
representatives of the Medicaid managed care health
plans and representatives of provider associations
representing the majority of providers within the
identified provider industry; and
(C) such rules shall be published for a review and
comment period of no less than 30 days on the
Department's website with final rules remaining
available on the Department's website.
The rules on payment resolutions shall include, but

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not be limited to:
(A) the extension of the timely filing period;
(B) retroactive prior authorizations; and
(C) guaranteed minimum payment rate of no less
than the current, as of the date of service,
fee-for-service rate, plus all applicable add-ons,
when the resulting service relationship is out of
network.
The rules shall be applicable for both MCO coverage
and fee-for-service coverage.
If the fee-for-service system is ultimately determined to
have been responsible for coverage on the date of service, the
Department shall provide for an extended period for claims
submission outside the standard timely filing requirements.
(g-6) MCO Performance Metrics Report.
(1) The Department shall publish, on at least a
quarterly basis, each MCO's operational performance,
including, but not limited to, the following categories of
metrics:
(A) claims payment, including timeliness and
accuracy;
(B) prior authorizations;
(C) grievance and appeals;
(D) utilization statistics;
(E) provider disputes;
(F) provider credentialing; and

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(G) member and provider customer service.
(2) The Department shall ensure that the metrics
report is accessible to providers online by January 1,
2017.
(3) The metrics shall be developed in consultation
with industry representatives of the Medicaid managed care
health plans and representatives of associations
representing the majority of providers within the
identified industry.
(4) Metrics shall be defined and incorporated into the
applicable Managed Care Policy Manual issued by the
Department.
(g-7) MCO claims processing and performance analysis. In
order to monitor MCO payments to hospital providers, pursuant
to Public Act 100-580, the Department shall post an analysis
of MCO claims processing and payment performance on its
website every 6 months. Such analysis shall include a review
and evaluation of a representative sample of hospital claims
that are rejected and denied for clean and unclean claims and
the top 5 reasons for such actions and timeliness of claims
adjudication, which identifies the percentage of claims
adjudicated within 30, 60, 90, and over 90 days, and the dollar
amounts associated with those claims.
(g-8) Dispute resolution process. The Department shall
maintain a provider complaint portal through which a provider
can submit to the Department unresolved disputes with an MCO.

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An unresolved dispute means an MCO's decision that denies in
whole or in part a claim for reimbursement to a provider for
health care services rendered by the provider to an enrollee
of the MCO with which the provider disagrees. Disputes shall
not be submitted to the portal until the provider has availed
itself of the MCO's internal dispute resolution process.
Disputes that are submitted to the MCO internal dispute
resolution process may be submitted to the Department of
Healthcare and Family Services' complaint portal no sooner
than 30 days after submitting to the MCO's internal process
and not later than 30 days after the unsatisfactory resolution
of the internal MCO process or 60 days after submitting the
dispute to the MCO internal process. Multiple claim disputes
involving the same MCO may be submitted in one complaint,
regardless of whether the claims are for different enrollees,
when the specific reason for non-payment of the claims
involves a common question of fact or policy. Within 10
business days of receipt of a complaint, the Department shall
present such disputes to the appropriate MCO, which shall then
have 30 days to issue its written proposal to resolve the
dispute. The Department may grant one 30-day extension of this
time frame to one of the parties to resolve the dispute. If the
dispute remains unresolved at the end of this time frame or the
provider is not satisfied with the MCO's written proposal to
resolve the dispute, the provider may, within 30 days, request
the Department to review the dispute and make a final

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determination. Within 30 days of the request for Department
review of the dispute, both the provider and the MCO shall
present all relevant information to the Department for
resolution and make individuals with knowledge of the issues
available to the Department for further inquiry if needed.
Within 30 days of receiving the relevant information on the
dispute, or the lapse of the period for submitting such
information, the Department shall issue a written decision on
the dispute based on contractual terms between the provider
and the MCO, contractual terms between the MCO and the
Department of Healthcare and Family Services and applicable
Medicaid policy. The decision of the Department shall be
final. By January 1, 2020, the Department shall establish by
rule further details of this dispute resolution process.
Disputes between MCOs and providers presented to the
Department for resolution are not contested cases, as defined
in Section 1-30 of the Illinois Administrative Procedure Act,
conferring any right to an administrative hearing.
(g-9)(1) The Department shall publish annually on its
website a report on the calculation of each managed care
organization's medical loss ratio showing the following:
(A) Premium revenue, with appropriate adjustments.
(B) Benefit expense, setting forth the aggregate
amount spent for the following:
(i) Direct paid claims.
(ii) Subcapitation payments.

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(iii) Other claim payments.
(iv) Direct reserves.
(v) Gross recoveries.
(vi) Expenses for activities that improve health
care quality as allowed by the Department.
(2) The medical loss ratio shall be calculated consistent
with federal law and regulation following a claims runout
period determined by the Department.
(g-10)(1) "Liability effective date" means the date on
which an MCO becomes responsible for payment for medically
necessary and covered services rendered by a provider to one
of its enrollees in accordance with the contract terms between
the MCO and the provider. The liability effective date shall
be the later of:
(A) The execution date of a network participation
contract agreement.
(B) The date the provider or its representative
submits to the MCO the complete and accurate standardized
roster form for the provider in the format approved by the
Department.
(C) The provider effective date contained within the
Department's provider enrollment subsystem within the
Illinois Medicaid Program Advanced Cloud Technology
(IMPACT) System.
(2) The standardized roster form may be submitted to the
MCO at the same time that the provider submits an enrollment

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application to the Department through IMPACT.
(3) By October 1, 2019, the Department shall require all
MCOs to update their provider directory with information for
new practitioners of existing contracted providers within 30
days of receipt of a complete and accurate standardized roster
template in the format approved by the Department provided
that the provider is effective in the Department's provider
enrollment subsystem within the IMPACT system. Such provider
directory shall be readily accessible for purposes of
selecting an approved health care provider and comply with all
other federal and State requirements.
(g-11) The Department shall work with relevant
stakeholders on the development of operational guidelines to
enhance and improve operational performance of Illinois'
Medicaid managed care program, including, but not limited to,
improving provider billing practices, reducing claim
rejections and inappropriate payment denials, and
standardizing processes, procedures, definitions, and response
timelines, with the goal of reducing provider and MCO
administrative burdens and conflict. The Department shall
include a report on the progress of these program improvements
and other topics in its Fiscal Year 2020 annual report to the
General Assembly.
(g-12) Notwithstanding any other provision of law, if the
Department or an MCO requires submission of a claim for
payment in a non-electronic format, a provider shall always be

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afforded a period of no less than 90 business days, as a
correction period, following any notification of rejection by
either the Department or the MCO to correct errors or
omissions in the original submission.
Under no circumstances, either by an MCO or under the
State's fee-for-service system, shall a provider be denied
payment for failure to comply with any timely submission
requirements under this Code or under any existing contract,
unless the non-electronic format claim submission occurs after
the initial 180 days following the latest date of service on
the claim, or after the 90 business days correction period
following notification to the provider of rejection or denial
of payment.
(g-13) Utilization Review Standardization and
Transparency.
(1) To ensure greater standardization and transparency
related to service authorization determinations, for all
individuals covered under the medical assistance program
and enrolled in the managed care program , including both
the fee-for-service and managed care programs, the
Department shall, in consultation with the MCOs, a
statewide association representing the MCOs, a statewide
association representing the majority of Illinois
hospitals, a statewide association representing
physicians, or any other interested parties deemed
appropriate by the Department, adopt administrative rules

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consistent with this subsection, in accordance with the
Illinois Administrative Procedure Act.
(2) No later than July 1, 2025, the Department shall
in accordance with the Illinois Administrative Procedure
Act file emergency rules, and adopt permanent rules no
later than November 28, 2025 October 1, 2025, which govern
MCO practices for dates of services on and after July 1,
2025, as follows:
(A) guidelines related to the publication of MCO
service authorization policies;
(B) procedures listed on the Medicare Inpatient
Only list published on January 1, 2025 by the Centers
for Medicare and Medicaid Services in Addendum B to
CMS-1809-FC that, due to medical complexity, must be
reimbursed under the applicable inpatient methodology,
when provided in the inpatient setting and billed as
an inpatient service;
(C) standardization of administrative forms used
in the member appeal process;
(D) limitations on second or subsequent medical
necessity review of a health care service already
authorized by the MCO or URO under a service
authorization program;
(E) standardization of peer-to-peer processes and
timelines;
(F) defined criteria for urgent and standard

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post-acute care and long-term acute care service
authorization requests; and
(G) standardized criteria for service
authorization programs for authorization of admission
to a long-term acute care hospital.
(3) The Department shall expand the scope of the
quality and compliance audits conducted by its contracted
external quality review organization to include, but not
be limited to:
(A) an analysis of the Medicaid MCO's compliance
with nationally recognized clinical decision
guidelines for inpatient and outpatient hospital
services;
(B) an analysis that compares and contrasts the
Medicaid MCO's service authorization determination
outcomes for inpatient and outpatient hospital
services to the outcomes of each other MCO plan and the
State's fee-for-service program model to evaluate
whether service authorization determinations are being
made consistently by all Medicaid MCOs to ensure that
all individuals are being treated in accordance with
equitable standards of care;
(C) an analysis, for each Medicaid MCO, of the
number of service authorization requests, including
requests for concurrent review of inpatient hospital
admissions and certification of inpatient hospital

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admissions, received, initially denied, overturned
through any post-denial process including, but not
limited to, enrollee or provider appeal, peer-to-peer
review, or the provider dispute resolution process,
denied but approved for a lower or different level of
care, and the number denied on final determination;
and
(D) provide a written report to the General
Assembly, detailing the items listed in this
subsection and any other metrics deemed necessary by
the Department, by the second April, following June 7,
2025 2024 (the effective date of Public Act 103-593),
and each April thereafter. The Department shall make
this report available within 30 days of delivery to
the General Assembly, on its public facing website.
(h) The Department shall not expand mandatory MCO
enrollment into new counties beyond those counties already
designated by the Department as of June 1, 2014 for the
individuals whose eligibility for medical assistance is not
the seniors or people with disabilities population until the
Department provides an opportunity for accountable care
entities and MCOs to participate in such newly designated
counties.
(h-5) Leading indicator data sharing. By January 1, 2024,
the Department shall obtain input from the Department of Human
Services, the Department of Juvenile Justice, the Department

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of Children and Family Services, the State Board of Education,
managed care organizations, providers, and clinical experts to
identify and analyze key indicators and data elements that can
be used in an analysis of lead indicators from assessments and
data sets available to the Department that can be shared with
managed care organizations and similar care coordination
entities contracted with the Department as leading indicators
for elevated behavioral health crisis risk for children,
including data sets such as the Illinois Medicaid
Comprehensive Assessment of Needs and Strengths (IM-CANS),
calls made to the State's Crisis and Referral Entry Services
(CARES) hotline, health services information from Health and
Human Services Innovators, or other data sets that may include
key indicators. The workgroup shall complete its
recommendations for leading indicator data elements on or
before September 1, 2024. To the extent permitted by State and
federal law, the identified leading indicators shall be shared
with managed care organizations and similar care coordination
entities contracted with the Department on or before December
1, 2024 for the purpose of improving care coordination with
the early detection of elevated risk. Leading indicators shall
be reassessed annually with stakeholder input. The Department
shall implement guidance to managed care organizations and
similar care coordination entities contracted with the
Department, so that the managed care organizations and care
coordination entities respond to lead indicators with services

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and interventions that are designed to help stabilize the
child.
(i) The requirements of this Section apply to contracts
with accountable care entities and MCOs entered into, amended,
or renewed after June 16, 2014 (the effective date of Public
Act 98-651).
(j) Health care information released to managed care
organizations. A health care provider shall release to a
Medicaid managed care organization, upon request, and subject
to the Health Insurance Portability and Accountability Act of
1996 and any other law applicable to the release of health
information, the health care information of the MCO's
enrollee, if the enrollee has completed and signed a general
release form that grants to the health care provider
permission to release the recipient's health care information
to the recipient's insurance carrier.
(k) The Department of Healthcare and Family Services,
managed care organizations, a statewide organization
representing hospitals, and a statewide organization
representing safety-net hospitals shall explore ways to
support billing departments in safety-net hospitals.
(l) The requirements of this Section added by Public Act
102-4 shall apply to services provided on or after the first
day of the month that begins 60 days after April 27, 2021 (the
effective date of Public Act 102-4).
(m) Except where otherwise expressly specified, the

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requirements of this Section added by Public Act 103-593 shall
apply to services provided on and after July 1, 2026.
(Source: P.A. 103-546, eff. 8-11-23; 103-593, eff. 6-7-24;
103-885, eff. 8-9-24; 104-9, eff. 6-16-25; 104-417, eff.
8-15-25.)
ARTICLE 180.
Section 180-5. The Psychiatric Residential Treatment
Facilities (PRTF) Act is amended by changing Sections 10 and
15 as follows:
(405 ILCS 142/10)
Sec. 10. PRTF services.
(a) The Department shall establish an Illinois Psychiatric
Residential Treatment Facilities (PRTF) program that is
family-driven, youth-guided, and trauma-informed, and includes
youth and family involvement in all aspects of care planning.
The Illinois PRTF program design shall establish meaningful
opportunities for youth and families to be involved in the
design, monitoring, and oversight of PRTF services.
(b) By September 1, 2027 By January 1, 2026, the
Department shall submit a State Plan Amendment to the Centers
for Medicare and Medicaid Services to establish coverage of
federally authorized, medically necessary inpatient
psychiatric services delivered by a certified PRTF to medical

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assistance beneficiaries under 21 years of age.
(c) The Department shall adopt rules to implement the
Illinois PRTF program. The rules may establish the services,
standards, and requirements for participation in the program
to comply with all applicable federal statutes, regulations,
requirements, and policies. The rules proposed by the
Department may take into consideration the recommendations of
the PRTF Advisory Committee, as outlined in Section 20. At a
minimum, the rules shall include the following:
(1) Certification and participation requirements for
PRTF providers in compliance with all applicable federal
laws, regulations, requirements, and policies, including
those found at 42 CFR 441, Subpart D and 42 CFR 483,
Subpart G or any successor regulations.
(2) Monitoring and oversight of PRTF services,
including on-site review protocols that include scheduled
and unannounced on-site visits. Each provider seeking PRTF
certification shall minimally have an on-site review prior
to initiating services and all PRTFs shall have at least
one on-site review annually thereafter.
(3) Utilization management criteria to ensure that
PRTF services are provided as medically necessary and
emphasize clinically appropriate patient transitions back
to the community, including, but not limited to, service
authorization, documentation, and treatment plan
requirements for initial stay reviews and continued stay

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reviews.
(4) A limit on allowable beds at any one PRTF, not to
exceed 40 total beds, unless waived in writing by the
Director of the Department.
(5) A limit on the number of new PRTF facilities to be
certified in any State fiscal year.
(6) A requirement that PRTFs are distinct, standalone
non-hospital entities not physically attached or adjacent
to any other type of facility engaged in providing
congregate care.
(7) A requirement that, in order to obtain PRTF
certification, providers must undergo a survey from the
State Survey Agency, the Department of Public Health, to
establish the provider's compliance with the Conditions of
Participation for PRTFs outlined in 42 CFR 483, Subpart G
and the Interpretive Guidelines issued by the Centers for
Medicare and Medicaid Services.
(8) A requirement that, in order to obtain PRTF
certification, providers be accredited from one of the
following organizations identified in 42 CFR 441.151, or
any successor regulations:
(i) Joint Commission on Accreditation of
Healthcare Organizations.
(ii) The Commission on Accreditation of
Rehabilitation Facilities.
(iii) The Council on Accreditation of Services for

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Families and Children.
(iv) Any other accrediting organization with
comparable standards recognized by the Department.
(9) Requirements for the reporting of emergency safety
interventions and serious occurrences to the Department
and the State-designated Protection and Advocacy System no
later than the close of business the next business day
after the intervention or occurrence.
(Source: P.A. 104-147, eff. 8-1-25.)
(405 ILCS 142/15)
Sec. 15. PRTF capacity analysis.
(a) The Department shall establish, and update as needed,
a methodology for completing a statewide PRTF capacity
analysis for the purposes of identifying capacity needs for
PRTF services under the Illinois Medical Assistance Program.
The Department shall utilize the PRTF capacity analysis to
inform its certification and enrollment of PRTF providers. The
capacity analysis shall minimally include:
(1) An analysis of aggregate service utilization data
for Medicaid eligible individuals under the age of 21,
including community-based services, behavioral health
crisis services, and inpatient psychiatric hospitalization
services.
(2) Identification of locations across the State with
demonstrated need for PRTF services and locations with

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demonstrated surplus of PRTF service capacity.
(3) Consideration of specialized treatment needs based
on increased utilization of out-of-state facilities to
address specialized treatment needs.
(4) Other factors of consideration identified by the
Department as necessary to support access to care,
compliance with the federal Medicaid program, and all
other applicable federal or State laws, regulations,
policies, requirements, and programs impacting Illinois'
children's behavioral health service delivery system.
(5) Recommendations to the Department and the PRTF
Advisory Committee on capacity needs within the Illinois
PRTF program. The recommendations shall seek to avoid the
concentration of PRTF facilities in any particular
community or area of the State to promote access for
families or guardians to visit patients when appropriate.
(b) The Department's methodology, completed analyses, and
outcomes shall be published on its website, with an initial
PRTF capacity analysis to be published by no later than April
1, 2027 January 1, 2026.
(c) The Department's PRTF capacity analysis shall be
updated at a minimum of every 5 years and shall be performed
consistent with the Department's published methodology.
(Source: P.A. 104-147, eff. 8-1-25.)
ARTICLE 185.

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Section 185-5. The Illinois Public Aid Code is amended by
changing Section 1-8.5 as follows:
(305 ILCS 5/1-8.5)
Sec. 1-8.5. Eligibility for medical assistance during
periods of incarceration or detention.
(a) To the extent permitted by federal law and
notwithstanding any other provision of this Code, the
Department of Healthcare and Family Services shall not cancel
a person's eligibility for medical assistance, nor shall the
Department deny a person's application for medical assistance,
solely because that person has become or is an inmate of a
public institution, including, but not limited to, a county
jail, juvenile detention center, or State correctional
facility. The person may be and remain enrolled for medical
assistance as long as all other eligibility criteria are met.
(b) The Department may adopt rules to permit a person to
apply for medical assistance while he or she is an inmate of a
public institution as described in subsection (a). The rules
may limit applications to persons who would be likely to
qualify for medical assistance if they resided in the
community. Any such person who is not already enrolled for
medical assistance may apply for medical assistance prior to
the date of scheduled release or discharge from a penal
institution or county jail or similar status.

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(c) Except as provided under Section 17 of the County Jail
Act, the Department shall not be responsible to provide
medical assistance under this Code for any medical care,
services, or supplies provided to a person while he or she is
an inmate of a public institution as described in subsection
(a). The responsibility for providing medical care shall
remain as otherwise provided by law with the Department of
Corrections, county, or other arresting authority. The
Department may seek federal financial participation, to the
extent that it is available and with the cooperation of the
Department of Juvenile Justice, the Department of Corrections,
or the relevant county, for the costs of those services.
(c-1) Notwithstanding subsection (c), the Department may
provide medical assistance under this Code for medical care,
services, and supplies provided to a person while he or she is
an inmate of a public institution as described in subsection
(a) only to the extent required by the federal Medicaid
program, the Children's Health Insurance Program, or otherwise
authorized under a federally approved 1115 Waiver, State Plan
Amendment, or other federal authority. The medical care,
services, and supplies covered, and any other standards,
limitations, or conditions for eligibility and coverage, shall
be established by rule by the Department in accordance with
the applicable federal requirement, waiver, State Plan
amendment, or other authority.
(d) To the extent permitted under State and federal law,

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the Department shall develop procedures to expedite required
periodic reviews of continued eligibility for persons
described in subsection (a).
(e) Counties, the Department of Juvenile Justice, the
Department of Human Services, and the Department of
Corrections shall cooperate with the Department in
administering this Section. That cooperation shall include
managing eligibility processing and sharing information
sufficient to inform the Department, in a manner established
by the Department, that a person enrolled in the medical
assistance program has been detained or incarcerated.
(f) The Department shall resume responsibility for
providing medical assistance upon release of the person to the
community as long as all of the following apply:
(1) The person is enrolled for medical assistance at
the time of release.
(2) Neither a county, the Department of Juvenile
Justice, the Department of Corrections, nor any other
criminal justice authority continues to bear
responsibility for the person's medical care.
(3) The county, the Department of Juvenile Justice, or
the Department of Corrections provides timely notice of
the date of release in a manner established by the
Department.
(g) This Section applies on and after December 31, 2011.
(Source: P.A. 98-139, eff. 1-1-14; 99-415, eff. 8-20-15.)

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ARTICLE 190.
Section 190-5. The Illinois Public Aid Code is amended by
changing Sections 5-30.1 and 5-30.18 as follows:
(305 ILCS 5/5-30.1)
Sec. 5-30.1. Managed care protections.
(a) As used in this Section:
"Managed care organization" or "MCO" means any entity
which contracts with the Department to provide services where
payment for medical services is made on a capitated basis.
"Emergency services" means health care items and services,
including inpatient and outpatient hospital services,
furnished or required to evaluate and stabilize an emergency
medical condition. "Emergency services" include inpatient
stabilization services furnished during the inpatient
stabilization period. "Emergency services" do not include
post-stabilization medical services.
"Emergency medical condition" means a medical condition
manifesting itself by acute symptoms of sufficient severity,
regardless of the final diagnosis given, such that a prudent
layperson, who possesses an average knowledge of health and
medicine, could reasonably expect the absence of immediate
medical attention to result in:
(1) placing the health of the individual (or, with

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respect to a pregnant woman, the health of the woman or her
unborn child) in serious jeopardy;
(2) serious impairment to bodily functions;
(3) serious dysfunction of any bodily organ or part;
(4) inadequately controlled pain; or
(5) with respect to a pregnant woman who is having
contractions:
(A) inadequate time to complete a safe transfer to
another hospital before delivery; or
(B) a transfer to another hospital may pose a
threat to the health or safety of the woman or unborn
child.
"Emergency medical screening examination" means a medical
screening examination and evaluation by a physician licensed
to practice medicine in all its branches or, to the extent
permitted by applicable laws, by other appropriately licensed
personnel under the supervision of or in collaboration with a
physician licensed to practice medicine in all its branches to
determine whether the need for emergency services exists.
"Health care services" means mean any medical or
behavioral health services covered under the medical
assistance program that are subject to review under a service
authorization program.
"Inpatient stabilization period" means the initial 72
hours of inpatient stabilization services, beginning from the
date and time of the order for inpatient admission to the

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hospital.
"Inpatient stabilization services" means mean emergency
services furnished in the inpatient setting at a hospital
pursuant to an order for inpatient admission by a physician or
other qualified practitioner who has admitting privileges at
the hospital, as permitted by State law, to stabilize an
emergency medical condition following an emergency medical
screening examination.
"Post-stabilization medical services" means health care
services provided to an enrollee that are furnished in a
hospital by a provider that is qualified to furnish such
services and determined to be medically necessary by the
provider and directly related to the emergency medical
condition following stabilization.
"Provider" means a facility or individual who is actively
enrolled in the medical assistance program and licensed or
otherwise authorized to order, prescribe, refer, or render
health care services in this State.
"Service authorization determination" means a decision
made by a service authorization program in advance of,
concurrent to, or after the provision of a health care service
to approve, change the level of care, partially deny, deny, or
otherwise limit coverage and reimbursement for a health care
service upon review of a service authorization request.
"Service authorization program" means any utilization
review, utilization management, peer review, quality review,

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or other medical management activity conducted by an MCO, or
its contracted utilization review organization, including, but
not limited to, prior authorization, prior approval,
pre-certification, concurrent review, retrospective review, or
certification of admission, of health care services provided
in the inpatient or outpatient hospital setting.
"Service authorization request" means a request by a
provider to a service authorization program to determine
whether a health care service meets the reimbursement
eligibility requirements for medically necessary, clinically
appropriate care, resulting in the issuance of a service
authorization determination.
"Utilization review organization" or "URO" means an MCO's
utilization review department or a peer review organization or
quality improvement organization that contracts with an MCO to
administer a service authorization program and make service
authorization determinations.
(b) As provided by Section 5-16.12, managed care
organizations are subject to the provisions of the Managed
Care Reform and Patient Rights Act.
(c) An MCO shall pay any provider of emergency services,
including for inpatient stabilization services provided during
the inpatient stabilization period, that does not have in
effect a contract with the contracted Medicaid MCO. The
default rate of reimbursement shall be the rate paid under
Illinois Medicaid fee-for-service program methodology,

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including all policy adjusters, including but not limited to
Medicaid High Volume Adjustments, Medicaid Percentage
Adjustments, Outpatient High Volume Adjustments, and all
outlier add-on adjustments to the extent such adjustments are
incorporated in the development of the applicable MCO
capitated rates.
(d) (Blank).
(e) Notwithstanding any other provision of law, the
following requirements apply to MCOs in determining payment
for all emergency services, including inpatient stabilization
services provided during the inpatient stabilization period:
(1) The MCO shall not impose any service authorization
program requirements for emergency services, including,
but not limited to, prior authorization, prior approval,
pre-certification, certification of admission, concurrent
review, or retrospective review.
(A) Notification period: Hospitals shall notify
the enrollee's Medicaid MCO within 48 hours of the
date and time the order for inpatient admission is
written. Notification shall be limited to advising the
MCO that the patient has been admitted to a hospital
inpatient level of care.
(B) If the admitting hospital complies with the
notification provisions of subparagraph (A), the
Medicaid MCO may not initiate concurrent review before
the end of the inpatient stabilization period. If the

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admitting hospital does not comply with the
notification requirements in subparagraph (A), the
Medicaid MCO may initiate concurrent review for the
continuation of the stay beginning at the end of the
48-hour notification period.
(C) Coverage for services provided during the
48-hour notification period may not be retrospectively
denied.
(2) The MCO shall cover emergency services provided to
enrollees who are temporarily away from their residence
and outside the contracting area to the extent that the
enrollees would be entitled to the emergency services if
they still were within the contracting area.
(3) The MCO shall have no obligation to cover
emergency services provided on an emergency basis that are
not covered services under the contract between the MCO
and the Department.
(4) The MCO shall not condition coverage for emergency
services on the treating provider notifying the MCO of the
enrollee's emergency medical screening examination and
treatment within 10 days after presentation for emergency
services.
(5) The determination of the attending emergency
physician, or the practitioner responsible for the
enrollee's care at the hospital, of whether an enrollee
requires inpatient stabilization services, can be

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stabilized in the outpatient setting, or is sufficiently
stabilized for discharge or transfer to another setting,
shall be binding on the MCO. The MCO shall cover and
reimburse providers for emergency services as billed by
the provider for all enrollees whether the emergency
services are provided by an affiliated or non-affiliated
provider, except in cases of fraud. The MCO shall
reimburse inpatient stabilization services provided during
the inpatient stabilization period and billed as inpatient
level of care based on the appropriate inpatient
reimbursement methodology.
(6) The MCO's financial responsibility for
post-stabilization medical services it has not
pre-approved ends when:
(A) a plan physician with privileges at the
treating hospital assumes responsibility for the
enrollee's care;
(B) a plan physician assumes responsibility for
the enrollee's care through transfer;
(C) a contracting entity representative and the
treating physician reach an agreement concerning the
enrollee's care; or
(D) the enrollee is discharged.
(e-5) An MCO shall pay for all post-stabilization medical
services as a covered service in any of the following
situations:

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(1) the MCO or its URO authorized such services;
(2) such services were administered to maintain the
enrollee's stabilized condition within one hour after a
request to the MCO for authorization of further
post-stabilization services;
(3) the MCO or its URO did not respond to a request to
authorize such services within one hour;
(4) the MCO or its URO could not be contacted; or
(5) the MCO or its URO and the treating provider, if
the treating provider is a non-affiliated provider, could
not reach an agreement concerning the enrollee's care and
an affiliated provider was unavailable for a consultation,
in which case the MCO must pay for such services rendered
by the treating non-affiliated provider until an
affiliated provider was reached and either concurred with
the treating non-affiliated provider's plan of care or
assumed responsibility for the enrollee's care. Such
payment shall be made at the default rate of reimbursement
paid under the State's Medicaid fee-for-service program
methodology, including all policy adjusters, including,
but not limited to, Medicaid High Volume Adjustments,
Medicaid Percentage Adjustments, Outpatient High Volume
Adjustments, and all outlier add-on adjustments to the
extent that such adjustments are incorporated in the
development of the applicable MCO capitated rates.
(f) Network adequacy and transparency.

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(1) The Department shall:
(A) ensure that an adequate provider network is in
place, taking into consideration health professional
shortage areas and medically underserved areas;
(B) publicly release an explanation of its process
for analyzing network adequacy;
(C) periodically ensure that an MCO continues to
have an adequate network in place;
(D) require MCOs, including Medicaid Managed Care
Entities as defined in Section 5-30.2, to meet
provider directory requirements under Section 5-30.3;
(E) require MCOs to ensure that any
Medicaid-certified provider under contract with an MCO
and previously submitted on a roster on the date of
service is paid for any medically necessary,
Medicaid-covered, and authorized service rendered to
any of the MCO's enrollees, regardless of inclusion on
the MCO's published and publicly available directory
of available providers; and
(F) require MCOs, including Medicaid Managed Care
Entities as defined in Section 5-30.2, to meet each of
the requirements under subsection (d-5) of Section 10
of the Network Adequacy and Transparency Act; with
necessary exceptions to the MCO's network to ensure
that admission and treatment with a provider or at a
treatment facility in accordance with the network

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adequacy standards in paragraph (3) of subsection
(d-5) of Section 10 of the Network Adequacy and
Transparency Act is limited to providers or facilities
that are Medicaid certified.
(2) Each MCO shall confirm its receipt of information
submitted specific to physician or dentist additions or
physician or dentist deletions from the MCO's provider
network within 3 days after receiving all required
information from contracted physicians or dentists, and
electronic physician and dental directories must be
updated consistent with current rules as published by the
Centers for Medicare and Medicaid Services or its
successor agency.
(g) Timely payment of claims.
(1) The MCO shall pay a claim within 30 days of
receiving a claim that contains all the essential
information needed to adjudicate the claim.
(2) The MCO shall notify the billing party of its
inability to adjudicate a claim within 30 days of
receiving that claim.
(3) The MCO shall pay a penalty that is at least equal
to the timely payment interest penalty imposed under
Section 368a of the Illinois Insurance Code for any claims
not timely paid.
(A) When an MCO is required to pay a timely payment
interest penalty to a provider, the MCO must calculate

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and pay the timely payment interest penalty that is
due to the provider within 30 days after the payment of
the claim. In no event shall a provider be required to
request or apply for payment of any owed timely
payment interest penalties.
(B) Such payments shall be reported separately
from the claim payment for services rendered to the
MCO's enrollee and clearly identified as interest
payments.
(4)(A) The Department shall require MCOs to expedite
payments to providers identified on the Department's
expedited provider list, determined in accordance with 89
Ill. Adm. Code 140.71(b), on a schedule at least as
frequently as the providers are paid under the
Department's fee-for-service expedited provider schedule.
(B) Compliance with the expedited provider requirement
may be satisfied by an MCO through the use of a Periodic
Interim Payment (PIP) program that has been mutually
agreed to and documented between the MCO and the provider,
if the PIP program ensures that any expedited provider
receives regular and periodic payments based on prior
period payment experience from that MCO. Total payments
under the PIP program may be reconciled against future PIP
payments on a schedule mutually agreed to between the MCO
and the provider.
(C) The Department shall share at least monthly its

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expedited provider list and the frequency with which it
pays providers on the expedited list.
(g-5) Recognizing that the rapid transformation of the
Illinois Medicaid program may have unintended operational
challenges for both payers and providers:
(1) in no instance shall a medically necessary covered
service rendered in good faith, based upon eligibility
information documented by the provider, be denied coverage
or diminished in payment amount if the eligibility or
coverage information available at the time the service was
rendered is later found to be inaccurate in the assignment
of coverage responsibility between MCOs or the
fee-for-service system, except for instances when an
individual is deemed to have not been eligible for
coverage under the Illinois Medicaid program; and
(2) the Department shall, by December 31, 2016, adopt
rules establishing policies that shall be included in the
Medicaid managed care policy and procedures manual
addressing payment resolutions in situations in which a
provider renders services based upon information obtained
after verifying a patient's eligibility and coverage plan
through either the Department's current enrollment system
or a system operated by the coverage plan identified by
the patient presenting for services:
(A) such medically necessary covered services
shall be considered rendered in good faith;

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(B) such policies and procedures shall be
developed in consultation with industry
representatives of the Medicaid managed care health
plans and representatives of provider associations
representing the majority of providers within the
identified provider industry; and
(C) such rules shall be published for a review and
comment period of no less than 30 days on the
Department's website with final rules remaining
available on the Department's website.
The rules on payment resolutions shall include, but
not be limited to:
(A) the extension of the timely filing period;
(B) retroactive prior authorizations; and
(C) guaranteed minimum payment rate of no less
than the current, as of the date of service,
fee-for-service rate, plus all applicable add-ons,
when the resulting service relationship is out of
network.
The rules shall be applicable for both MCO coverage
and fee-for-service coverage.
If the fee-for-service system is ultimately determined to
have been responsible for coverage on the date of service, the
Department shall provide for an extended period for claims
submission outside the standard timely filing requirements.
(g-6) MCO Performance Metrics Report.

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(1) The Department shall publish, on at least a
quarterly basis, each MCO's operational performance,
including, but not limited to, the following categories of
metrics:
(A) claims payment, including timeliness and
accuracy;
(B) prior authorizations;
(C) grievance and appeals;
(D) utilization statistics;
(E) provider disputes;
(F) provider credentialing; and
(G) member and provider customer service.
(2) The Department shall ensure that the metrics
report is accessible to providers online by January 1,
2017.
(3) The metrics shall be developed in consultation
with industry representatives of the Medicaid managed care
health plans and representatives of associations
representing the majority of providers within the
identified industry.
(4) Metrics shall be defined and incorporated into the
applicable Managed Care Policy Manual issued by the
Department.
(g-7) MCO claims processing and performance analysis. In
order to monitor MCO payments to hospital providers, pursuant
to Public Act 100-580, the Department shall post an analysis

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of MCO claims processing and payment performance on its
website every 6 months. Such analysis shall include a review
and evaluation of a representative sample of hospital claims
that are rejected and denied for clean and unclean claims and
the top 5 reasons for such actions and timeliness of claims
adjudication, which identifies the percentage of claims
adjudicated within 30, 60, 90, and over 90 days, and the dollar
amounts associated with those claims.
(g-8) Dispute resolution process. The Department shall
maintain a provider complaint portal through which a provider
can submit to the Department unresolved disputes with an MCO.
An unresolved dispute means an MCO's decision that denies in
whole or in part a claim for reimbursement to a provider for
health care services rendered by the provider to an enrollee
of the MCO with which the provider disagrees. Disputes shall
not be submitted to the portal until the provider has availed
itself of the MCO's internal dispute resolution process.
Disputes that are submitted to the MCO internal dispute
resolution process may be submitted to the Department of
Healthcare and Family Services' complaint portal no sooner
than 30 days after submitting to the MCO's internal process
and not later than 30 days after the unsatisfactory resolution
of the internal MCO process or 60 days after submitting the
dispute to the MCO internal process. Multiple claim disputes
involving the same MCO may be submitted in one complaint,
regardless of whether the claims are for different enrollees,

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when the specific reason for non-payment of the claims
involves a common question of fact or policy. Within 10
business days of receipt of a complaint, the Department shall
present such disputes to the appropriate MCO, which shall then
have 30 days to issue its written proposal to resolve the
dispute. The Department may grant one 30-day extension of this
time frame to one of the parties to resolve the dispute. If the
dispute remains unresolved at the end of this time frame or the
provider is not satisfied with the MCO's written proposal to
resolve the dispute, the provider may, within 30 days, request
the Department to review the dispute and make a final
determination. Within 30 days of the request for Department
review of the dispute, both the provider and the MCO shall
present all relevant information to the Department for
resolution and make individuals with knowledge of the issues
available to the Department for further inquiry if needed.
Within 30 days of receiving the relevant information on the
dispute, or the lapse of the period for submitting such
information, the Department shall issue a written decision on
the dispute based on contractual terms between the provider
and the MCO, contractual terms between the MCO and the
Department of Healthcare and Family Services and applicable
Medicaid policy. The decision of the Department shall be
final. By January 1, 2020, the Department shall establish by
rule further details of this dispute resolution process.
Disputes between MCOs and providers presented to the

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Department for resolution are not contested cases, as defined
in Section 1-30 of the Illinois Administrative Procedure Act,
conferring any right to an administrative hearing.
(g-9)(1) The Department shall publish annually on its
website a report on the calculation of each managed care
organization's medical loss ratio showing the following:
(A) Premium revenue, with appropriate adjustments.
(B) Benefit expense, setting forth the aggregate
amount spent for the following:
(i) Direct paid claims.
(ii) Subcapitation payments.
(iii) Other claim payments.
(iv) Direct reserves.
(v) Gross recoveries.
(vi) Expenses for activities that improve health
care quality as allowed by the Department.
(2) The medical loss ratio shall be calculated consistent
with federal law and regulation following a claims runout
period determined by the Department.
(g-10)(1) "Liability effective date" means the date on
which an MCO becomes responsible for payment for medically
necessary and covered services rendered by a provider to one
of its enrollees in accordance with the contract terms between
the MCO and the provider. The liability effective date shall
be the later of:
(A) The execution date of a network participation

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contract agreement.
(B) The date the provider or its representative
submits to the MCO the complete and accurate standardized
roster form for the provider in the format approved by the
Department.
(C) The provider effective date contained within the
Department's provider enrollment subsystem within the
Illinois Medicaid Program Advanced Cloud Technology
(IMPACT) System.
(2) The standardized roster form may be submitted to the
MCO at the same time that the provider submits an enrollment
application to the Department through IMPACT.
(3) By October 1, 2019, the Department shall require all
MCOs to update their provider directory with information for
new practitioners of existing contracted providers within 30
days of receipt of a complete and accurate standardized roster
template in the format approved by the Department provided
that the provider is effective in the Department's provider
enrollment subsystem within the IMPACT system. Such provider
directory shall be readily accessible for purposes of
selecting an approved health care provider and comply with all
other federal and State requirements.
(g-11) The Department shall work with relevant
stakeholders on the development of operational guidelines to
enhance and improve operational performance of Illinois'
Medicaid managed care program, including, but not limited to,

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improving provider billing practices, reducing claim
rejections and inappropriate payment denials, and
standardizing processes, procedures, definitions, and response
timelines, with the goal of reducing provider and MCO
administrative burdens and conflict. The Department shall
include a report on the progress of these program improvements
and other topics in its Fiscal Year 2020 annual report to the
General Assembly.
(g-12) Notwithstanding any other provision of law, if the
Department or an MCO requires submission of a claim for
payment in a non-electronic format, a provider shall always be
afforded a period of no less than 90 business days, as a
correction period, following any notification of rejection by
either the Department or the MCO to correct errors or
omissions in the original submission.
Under no circumstances, either by an MCO or under the
State's fee-for-service system, shall a provider be denied
payment for failure to comply with any timely submission
requirements under this Code or under any existing contract,
unless the non-electronic format claim submission occurs after
the initial 180 days following the latest date of service on
the claim, or after the 90 business days correction period
following notification to the provider of rejection or denial
of payment.
(g-13) Utilization Review Standardization and
Transparency.

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(1) To ensure greater standardization and transparency
related to service authorization determinations, for all
individuals covered under the medical assistance program,
including both the fee-for-service and managed care
programs, the Department shall, in consultation with the
MCOs, a statewide association representing the MCOs, a
statewide association representing the majority of
Illinois hospitals, a statewide association representing
physicians, or any other interested parties deemed
appropriate by the Department, adopt administrative rules
consistent with this subsection, in accordance with the
Illinois Administrative Procedure Act.
(2) No later than July 1, 2025, the Department shall
in accordance with the Illinois Administrative Procedure
Act file emergency rules, and adopt permanent rules no
later than October 1, 2025, which govern MCO practices for
dates of services on and after July 1, 2025, as follows:
(A) guidelines related to the publication of MCO
authorization policies;
(B) procedures that, due to medical complexity,
must be reimbursed under the applicable inpatient
methodology, when provided in the inpatient setting
and billed as an inpatient service;
(C) standardization of administrative forms used
in the member appeal process;
(D) limitations on second or subsequent medical

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necessity review of a health care service already
authorized by the MCO or URO under a service
authorization program;
(E) standardization of peer-to-peer processes and
timelines;
(F) defined criteria for urgent and standard
post-acute care and long-term acute care service
authorization requests; and
(G) standardized criteria for service
authorization programs for authorization of admission
to a long-term acute care hospital.
(3) The Department shall expand the scope of the
quality and compliance audits conducted by its contracted
external quality review organization to include, but not
be limited to:
(A) an analysis of the Medicaid MCO's compliance
with nationally recognized clinical decision
guidelines;
(B) an analysis that compares and contrasts the
Medicaid MCO's service authorization determination
outcomes to the outcomes of each other MCO plan and the
State's fee-for-service program model to evaluate
whether service authorization determinations are being
made consistently by all Medicaid MCOs to ensure that
all individuals are being treated in accordance with
equitable standards of care;

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(C) an analysis, for each Medicaid MCO, of the
number of service authorization requests, including
requests for concurrent review and certification of
admissions, received, initially denied, overturned
through any post-denial process including, but not
limited to, enrollee or provider appeal, peer-to-peer
review, or the provider dispute resolution process,
denied but approved for a lower or different level of
care, and the number denied on final determination;
and
(D) provide a written report to the General
Assembly, detailing the items listed in this
subsection and any other metrics deemed necessary by
the Department, by the second April, following June 7,
2024 (the effective date of Public Act 103-593), and
each April thereafter. The Department shall make this
report available within 30 days of delivery to the
General Assembly, on its public facing website.
(h) The Department shall not expand mandatory MCO
enrollment into new counties beyond those counties already
designated by the Department as of June 1, 2014 for the
individuals whose eligibility for medical assistance is not
the seniors or people with disabilities population until the
Department provides an opportunity for accountable care
entities and MCOs to participate in such newly designated
counties.

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(h-5) Leading indicator data sharing. By January 1, 2024,
the Department shall obtain input from the Department of Human
Services, the Department of Juvenile Justice, the Department
of Children and Family Services, the State Board of Education,
managed care organizations, providers, and clinical experts to
identify and analyze key indicators and data elements that can
be used in an analysis of lead indicators from assessments and
data sets available to the Department that can be shared with
managed care organizations and similar care coordination
entities contracted with the Department as leading indicators
for elevated behavioral health crisis risk for children,
including data sets such as the Illinois Medicaid
Comprehensive Assessment of Needs and Strengths (IM-CANS),
calls made to the State's Crisis and Referral Entry Services
(CARES) hotline, health services information from Health and
Human Services Innovators, or other data sets that may include
key indicators. The workgroup shall complete its
recommendations for leading indicator data elements on or
before September 1, 2024. To the extent permitted by State and
federal law, the identified leading indicators shall be shared
with managed care organizations and similar care coordination
entities contracted with the Department on or before December
1, 2024 for the purpose of improving care coordination with
the early detection of elevated risk. Leading indicators shall
be reassessed annually with stakeholder input. The Department
shall implement guidance to managed care organizations and

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similar care coordination entities contracted with the
Department, so that the managed care organizations and care
coordination entities respond to lead indicators with services
and interventions that are designed to help stabilize the
child.
(i) The requirements of this Section apply to contracts
with accountable care entities and MCOs entered into, amended,
or renewed after June 16, 2014 (the effective date of Public
Act 98-651).
(j) Health care information released to managed care
organizations. A health care provider shall release to a
Medicaid managed care organization, upon request, and subject
to the Health Insurance Portability and Accountability Act of
1996 and any other law applicable to the release of health
information, the health care information of the MCO's
enrollee, if the enrollee has completed and signed a general
release form that grants to the health care provider
permission to release the recipient's health care information
to the recipient's insurance carrier.
(k) The Department of Healthcare and Family Services,
managed care organizations, a statewide organization
representing hospitals, and a statewide organization
representing safety-net hospitals shall explore ways to
support billing departments in safety-net hospitals.
(l) The requirements of this Section added by Public Act
102-4 shall apply to services provided on or after the first

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day of the month that begins 60 days after April 27, 2021 (the
effective date of Public Act 102-4).
(m) Except where otherwise expressly specified, the
requirements of this Section added by Public Act 103-593 shall
apply to services provided on and after July 1, 2027 July 1,
2026.
(Source: P.A. 103-546, eff. 8-11-23; 103-593, eff. 6-7-24;
103-885, eff. 8-9-24; 104-9, eff. 6-16-25; 104-417, eff.
8-15-25.)
(305 ILCS 5/5-30.18)
(Section scheduled to be repealed on December 31, 2030)
Sec. 5-30.18. Service authorization program performance.
(a) Definitions. As used in this Section:
"Gold Card provider" means a provider identified by each
Medicaid Managed Care Organization (MCO) as qualified under
the guidelines outlined by the Department in accordance with
subsection (c) and thereby granted a service authorization
exemption when ordering a health care service.
"Health care service" means any medical or behavioral
health service covered under the medical assistance program
that is rendered in the inpatient or outpatient hospital
setting, including hospital-based clinics, and subject to
review under a service authorization program.
"Provider" means an individual actively enrolled in the
medical assistance program and licensed or otherwise

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authorized to order, prescribe, refer, or render health care
services in this State, and, as determined by the Department,
may also include hospitals that submit service authorization
requests.
"Service authorization exemption" means an exception
granted by a Medicaid MCO to a provider under which all service
authorization requests for covered health care services,
excluding pharmacy services and durable medical equipment, are
automatically deemed to be medically necessary, clinically
appropriate, and approved for reimbursement as ordered.
"Service authorization program" means any utilization
review, utilization management, peer review, quality review,
or other medical management activity conducted in advance of,
concurrent to, or after the provision of a health care service
by a Medicaid MCO, either directly or through a contracted
utilization review organization (URO), including, but not
limited to, prior authorization, pre-certification,
certification of admission, concurrent review, and
retrospective review of health care services.
"Service authorization request" means a request by a
provider to a service authorization program to determine
whether a health care service that is otherwise covered under
the medical assistance program meets the reimbursement
requirements established by the Medicaid MCO, or its
contracted URO, for medically necessary, clinically
appropriate care and to issue a service authorization

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determination.
"Utilization review organization" or "URO" means a managed
care organization or other entity that has established or
administers one or more service authorization programs.
(b) In consultation with the Medicaid MCOs, a statewide
association representing managed care organizations, a
statewide association representing the majority of Illinois
hospitals, and a statewide association representing
physicians, the Department shall in accordance with the
Illinois Administrative Procedure Act, adopt administrative
rules no later than October July 1, 2026, consistent with this
Section, to require each Medicaid MCO to identify Gold Card
providers with such identification initially being effective
for health care services provided on and after January 1, 2027
July 1, 2026.
(c) The Department shall adopt rules, in accordance with
the Illinois Administrative Procedure Act, to implement this
Section that include, but are not limited to, the following
provisions:
(1) Require each Medicaid MCO to provide a service
authorization exemption to a provider if the provider has
submitted at least 50 service authorization requests to
its service authorization program in the preceding
calendar year and the service authorization program
approved at least 90% of all service authorization
requests, regardless of the type of health care services

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requested.
(2) Require that service authorization exemptions be
limited to services provided in an inpatient or outpatient
hospital setting inclusive of hospital-based clinics.
Service authorization exemptions under this Section shall
not pertain to pharmacy services and durable medical
equipment and supplies.
(3) The service authorization exemption shall be valid
for at least one year, shall be made by each Medicaid MCO
or its URO, and shall be binding on the Medicaid MCO and
its URO.
(4) The provider shall be required to continue to
document medically necessary, clinically appropriate care
and submit such documentation to the Medicaid MCO for the
purpose of continuous performance monitoring. If a
provider fails to maintain the 90% service authorization
standard, as determined on no more frequent a basis than
bi-annually, the provider's service authorization
exemption is subject to temporary or permanent suspension.
(5) Require that each Medicaid MCO publish on its
provider portal a list of all providers that have
qualified for a service authorization exemption or
indicate that a provider has qualified for a service
authorization exemption on its provider-facing provider
roster.
(6) Require that no later than June 1 of each calendar

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year, each Medicaid MCO shall provide written notification
to all providers who qualify for a service authorization
exemption, for the subsequent State fiscal year.
(7) Require that each Medicaid MCO or its URO use the
policies and guidelines published by the Department to
evaluate whether a provider meets the criteria to qualify
for a service authorization exemption and the conditions
under which a service authorization exemption may be
rescinded, including review of the provider's service
authorization determinations during the preceding calendar
year.
(8) Require each Medicaid MCO to provide the
Department a list of all providers who were denied a
service authorization exemption or had a previously
granted service authorization exemption suspended, with
such denials being subject to an annual audit conducted by
an independent third-party URO to ensure their
appropriateness.
(A) The independent third-party URO shall issue a
written report consistent with this paragraph.
(B) The independent third-party URO shall not be
owned by, affiliated with, or employed by any Medicaid
MCO or its contracted URO, nor shall it have any
financial interest in the Medicaid MCO's service
authorization exemption program.
(d) Each Medicaid MCO must have a standard method to

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accept and process professional claims and facility claims, as
billed by the provider, for a health care service that is
rendered, prescribed, or ordered by a provider granted a
service authorization exemption, except in cases of fraud.
(e) A service authorization program shall not deny,
partially deny, reduce the level of care, or otherwise limit
reimbursement to the rendering or supervising provider,
including the rendering facility, for health care services
ordered by a provider who qualifies for a service
authorization exemption, except in cases of fraud.
(f) This Section is repealed on December 31, 2030.
(Source: P.A. 103-593, eff. 6-7-24; 104-9, eff. 6-16-25.)
ARTICLE 195.
Section 195-5. The Illinois Insurance Code is amended by
changing Section 370c.1 as follows:
(215 ILCS 5/370c.1)
Sec. 370c.1. Mental, emotional, nervous, or substance use
disorder or condition parity.
(a) On and after July 23, 2021 (the effective date of
Public Act 102-135), every insurer that amends, delivers,
issues, or renews a group or individual policy of accident and
health insurance or a qualified health plan offered through
the Health Insurance Marketplace in this State providing

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coverage for hospital or medical treatment and for the
treatment of mental, emotional, nervous, or substance use
disorders or conditions shall ensure prior to policy issuance
that:
(1) the financial requirements applicable to such
mental, emotional, nervous, or substance use disorder or
condition benefits are no more restrictive than the
predominant financial requirements applied to
substantially all hospital and medical benefits covered by
the policy and that there are no separate cost-sharing
requirements that are applicable only with respect to
mental, emotional, nervous, or substance use disorder or
condition benefits; and
(2) the treatment limitations applicable to such
mental, emotional, nervous, or substance use disorder or
condition benefits are no more restrictive than the
predominant treatment limitations applied to substantially
all hospital and medical benefits covered by the policy
and that there are no separate treatment limitations that
are applicable only with respect to mental, emotional,
nervous, or substance use disorder or condition benefits.
(b) The following provisions shall apply concerning
aggregate lifetime limits:
(1) In the case of a group or individual policy of
accident and health insurance or a qualified health plan
offered through the Health Insurance Marketplace amended,

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delivered, issued, or renewed in this State on or after
September 9, 2015 (the effective date of Public Act
99-480) that provides coverage for hospital or medical
treatment and for the treatment of mental, emotional,
nervous, or substance use disorders or conditions the
following provisions shall apply:
(A) if the policy does not include an aggregate
lifetime limit on substantially all hospital and
medical benefits, then the policy may not impose any
aggregate lifetime limit on mental, emotional,
nervous, or substance use disorder or condition
benefits; or
(B) if the policy includes an aggregate lifetime
limit on substantially all hospital and medical
benefits (in this subsection referred to as the
"applicable lifetime limit"), then the policy shall
either:
(i) apply the applicable lifetime limit both
to the hospital and medical benefits to which it
otherwise would apply and to mental, emotional,
nervous, or substance use disorder or condition
benefits and not distinguish in the application of
the limit between the hospital and medical
benefits and mental, emotional, nervous, or
substance use disorder or condition benefits; or
(ii) not include any aggregate lifetime limit

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on mental, emotional, nervous, or substance use
disorder or condition benefits that is less than
the applicable lifetime limit.
(2) In the case of a policy that is not described in
paragraph (1) of subsection (b) of this Section and that
includes no or different aggregate lifetime limits on
different categories of hospital and medical benefits, the
Director shall establish rules under which subparagraph
(B) of paragraph (1) of subsection (b) of this Section is
applied to such policy with respect to mental, emotional,
nervous, or substance use disorder or condition benefits
by substituting for the applicable lifetime limit an
average aggregate lifetime limit that is computed taking
into account the weighted average of the aggregate
lifetime limits applicable to such categories.
(c) The following provisions shall apply concerning annual
limits:
(1) In the case of a group or individual policy of
accident and health insurance or a qualified health plan
offered through the Health Insurance Marketplace amended,
delivered, issued, or renewed in this State on or after
September 9, 2015 (the effective date of Public Act
99-480) that provides coverage for hospital or medical
treatment and for the treatment of mental, emotional,
nervous, or substance use disorders or conditions the
following provisions shall apply:

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(A) if the policy does not include an annual limit
on substantially all hospital and medical benefits,
then the policy may not impose any annual limits on
mental, emotional, nervous, or substance use disorder
or condition benefits; or
(B) if the policy includes an annual limit on
substantially all hospital and medical benefits (in
this subsection referred to as the "applicable annual
limit"), then the policy shall either:
(i) apply the applicable annual limit both to
the hospital and medical benefits to which it
otherwise would apply and to mental, emotional,
nervous, or substance use disorder or condition
benefits and not distinguish in the application of
the limit between the hospital and medical
benefits and mental, emotional, nervous, or
substance use disorder or condition benefits; or
(ii) not include any annual limit on mental,
emotional, nervous, or substance use disorder or
condition benefits that is less than the
applicable annual limit.
(2) In the case of a policy that is not described in
paragraph (1) of subsection (c) of this Section and that
includes no or different annual limits on different
categories of hospital and medical benefits, the Director
shall establish rules under which subparagraph (B) of

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paragraph (1) of subsection (c) of this Section is applied
to such policy with respect to mental, emotional, nervous,
or substance use disorder or condition benefits by
substituting for the applicable annual limit an average
annual limit that is computed taking into account the
weighted average of the annual limits applicable to such
categories.
(d) With respect to mental, emotional, nervous, or
substance use disorders or conditions, an insurer shall use
policies and procedures for the election and placement of
mental, emotional, nervous, or substance use disorder or
condition treatment drugs on its their formulary that are no
less favorable to the insured as those policies and procedures
the insurer uses for the selection and placement of drugs for
medical or surgical conditions and shall follow the expedited
coverage determination requirements for substance abuse
treatment drugs set forth in Section 45.2 of the Managed Care
Reform and Patient Rights Act.
(e) This Section shall be interpreted in a manner
consistent with all applicable federal parity regulations
including, but not limited to, the Paul Wellstone and Pete
Domenici Mental Health Parity and Addiction Equity Act of
2008, final regulations issued under the Paul Wellstone and
Pete Domenici Mental Health Parity and Addiction Equity Act of
2008 and final regulations applying the Paul Wellstone and
Pete Domenici Mental Health Parity and Addiction Equity Act of

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2008 to Medicaid managed care organizations, the Children's
Health Insurance Program, and alternative benefit plans.
(f) The provisions of subsections (b) and (c) of this
Section shall not be interpreted to allow the use of lifetime
or annual limits otherwise prohibited by State or federal law.
(g) As used in this Section:
"Financial requirement" includes deductibles, copayments,
coinsurance, and out-of-pocket maximums, but does not include
an aggregate lifetime limit or an annual limit subject to
subsections (b) and (c).
"Mental, emotional, nervous, or substance use disorder or
condition" means a condition or disorder that involves a
mental health condition or substance use disorder that falls
under any of the diagnostic categories listed in the mental
and behavioral disorders chapter of the current edition of the
International Classification of Disease or that is listed in
the most recent version of the Diagnostic and Statistical
Manual of Mental Disorders.
"Treatment limitation" includes limits on benefits based
on the frequency of treatment, number of visits, days of
coverage, days in a waiting period, or other similar limits on
the scope or duration of treatment. "Treatment limitation"
includes both quantitative treatment limitations, which are
expressed numerically (such as 50 outpatient visits per year),
and nonquantitative treatment limitations, which otherwise
limit the scope or duration of treatment. A permanent

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exclusion of all benefits for a particular condition or
disorder shall not be considered a treatment limitation.
"Nonquantitative treatment limitations" means those
limitations as described under federal regulations (26 CFR
54.9812-1). "Nonquantitative treatment limitations" include,
but are not limited to, those limitations described under
federal regulations 26 CFR 54.9812-1, 29 CFR 2590.712, and 45
CFR 146.136.
(h) The Department of Insurance shall implement the
following education initiatives:
(1) By January 1, 2016, the Department shall develop a
plan for a Consumer Education Campaign on parity. The
Consumer Education Campaign shall focus its efforts
throughout the State and include trainings in the
northern, southern, and central regions of the State, as
defined by the Department, as well as each of the 5 managed
care regions of the State as identified by the Department
of Healthcare and Family Services. Under this Consumer
Education Campaign, the Department shall: (1) by January
1, 2017, provide at least one live training in each region
on parity for consumers and providers and one webinar
training to be posted on the Department website and (2)
establish a consumer hotline to assist consumers in
navigating the parity process by March 1, 2017. By January
1, 2018 the Department shall issue a report to the General
Assembly on the success of the Consumer Education

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Campaign, which shall indicate whether additional training
is necessary or would be recommended.
(2) (Blank).
(3) Not later than March January 1 of each year,
beginning in calendar year 2027, the Department, in
conjunction with the Department of Healthcare and Family
Services, shall issue a joint report to the General
Assembly. The joint report shall be posted on each
respective department's website and provide an educational
presentation to the General Assembly. The report and
presentation shall:
(A) Cover the methodology the Departments use to
check for compliance with the federal Paul Wellstone
and Pete Domenici Mental Health Parity and Addiction
Equity Act of 2008, 42 U.S.C. 18031(j), and any
federal regulations or guidance relating to the
compliance and oversight of the federal Paul Wellstone
and Pete Domenici Mental Health Parity and Addiction
Equity Act of 2008 and 42 U.S.C. 18031(j).
(B) Cover the methodology the Departments use to
check for compliance with this Section and Sections
356z.23 and 370c of this Code.
(C) Identify market conduct examinations or, in
the case of the Department of Healthcare and Family
Services, audits conducted or completed during the
preceding 12-month period regarding compliance with

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parity in mental, emotional, nervous, and substance
use disorder or condition benefits under State and
federal laws and summarize the results of such market
conduct examinations and audits. This shall include:
(i) the number of market conduct examinations
and audits initiated and completed;
(ii) the benefit classifications examined by
each market conduct examination and audit;
(iii) the subject matter of each market
conduct examination and audit, including
quantitative and nonquantitative treatment
limitations; and
(iv) a summary of the basis for the final
decision rendered in each market conduct
examination and audit.
Individually identifiable information shall be
excluded from the reports consistent with federal
privacy protections.
(D) Detail any educational or corrective actions
the Departments have taken to ensure compliance with
the federal Paul Wellstone and Pete Domenici Mental
Health Parity and Addiction Equity Act of 2008, 42
U.S.C. 18031(j), this Section, and Sections 356z.23
and 370c of this Code.
(E) The report must be written in non-technical,
readily understandable language and shall be made

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available to the public by, among such other means as
the Departments find appropriate, posting the report
on the Departments' websites.
(i) The Parity Advancement Fund is created as a special
fund in the State treasury. Moneys from fines and penalties
collected from insurers for violations of this Section shall
be deposited into the Fund. Moneys deposited into the Fund for
appropriation by the General Assembly to the Department shall
be used for the purpose of providing financial support of the
Consumer Education Campaign, parity compliance advocacy, and
other initiatives that support parity implementation and
enforcement on behalf of consumers.
(j) (Blank).
(j-5) The Department of Insurance shall collect the
following information:
(1) The number of employment disability insurance
plans offered in this State, including, but not limited
to:
(A) individual short-term policies;
(B) individual long-term policies;
(C) group short-term policies; and
(D) group long-term policies.
(2) The number of policies referenced in paragraph (1)
of this subsection that limit mental health and substance
use disorder benefits.
(3) The average defined benefit period for the

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policies referenced in paragraph (1) of this subsection,
both for those policies that limit and those policies that
have no limitation on mental health and substance use
disorder benefits.
(4) Whether the policies referenced in paragraph (1)
of this subsection are purchased on a voluntary or
non-voluntary basis.
(5) The identities of the individuals, entities, or a
combination of the 2 that assume the cost associated with
covering the policies referenced in paragraph (1) of this
subsection.
(6) The average defined benefit period for plans that
cover physical disability and mental health and substance
abuse without limitation, including, but not limited to:
(A) individual short-term policies;
(B) individual long-term policies;
(C) group short-term policies; and
(D) group long-term policies.
(7) The average premiums for disability income
insurance issued in this State for:
(A) individual short-term policies that limit
mental health and substance use disorder benefits;
(B) individual long-term policies that limit
mental health and substance use disorder benefits;
(C) group short-term policies that limit mental
health and substance use disorder benefits;

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(D) group long-term policies that limit mental
health and substance use disorder benefits;
(E) individual short-term policies that include
mental health and substance use disorder benefits
without limitation;
(F) individual long-term policies that include
mental health and substance use disorder benefits
without limitation;
(G) group short-term policies that include mental
health and substance use disorder benefits without
limitation; and
(H) group long-term policies that include mental
health and substance use disorder benefits without
limitation.
The Department shall present its findings regarding
information collected under this subsection (j-5) to the
General Assembly no later than April 30, 2024. Information
regarding a specific insurance provider's contributions to the
Department's report shall be exempt from disclosure under
paragraph (t) of subsection (1) of Section 7 of the Freedom of
Information Act. The aggregated information gathered by the
Department shall not be exempt from disclosure under paragraph
(t) of subsection (1) of Section 7 of the Freedom of
Information Act.
(k) An insurer that amends, delivers, issues, or renews a
group or individual policy of accident and health insurance or

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a qualified health plan offered through the health insurance
marketplace in this State providing coverage for hospital or
medical treatment and for the treatment of mental, emotional,
nervous, or substance use disorders or conditions shall submit
an annual report, the format and definitions for which will be
determined by the Department and the Department of Healthcare
and Family Services and posted on their respective websites,
starting on September 1, 2023 and annually thereafter, that
contains the following information separately for inpatient
in-network benefits, inpatient out-of-network benefits,
outpatient in-network benefits, outpatient out-of-network
benefits, emergency care benefits, and prescription drug
benefits in the case of accident and health insurance or
qualified health plans, or inpatient, outpatient, emergency
care, and prescription drug benefits in the case of medical
assistance:
(1) A summary of the plan's pharmacy management
processes for mental, emotional, nervous, or substance use
disorder or condition benefits compared to those for other
medical benefits.
(2) A summary of the internal processes of review for
experimental benefits and unproven technology for mental,
emotional, nervous, or substance use disorder or condition
benefits and those for other medical benefits.
(3) A summary of how the plan's policies and
procedures for utilization management for mental,

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emotional, nervous, or substance use disorder or condition
benefits compare to those for other medical benefits.
(4) A description of the process used to develop or
select the medical necessity criteria for mental,
emotional, nervous, or substance use disorder or condition
benefits and the process used to develop or select the
medical necessity criteria for medical and surgical
benefits.
(5) Identification of all nonquantitative treatment
limitations that are applied to both mental, emotional,
nervous, or substance use disorder or condition benefits
and medical and surgical benefits within each
classification of benefits.
(6) The results of an analysis that demonstrates that
for the medical necessity criteria described in
subparagraph (A) and for each nonquantitative treatment
limitation identified in subparagraph (B), as written and
in operation, the processes, strategies, evidentiary
standards, or other factors used in applying the medical
necessity criteria and each nonquantitative treatment
limitation to mental, emotional, nervous, or substance use
disorder or condition benefits within each classification
of benefits are comparable to, and are applied no more
stringently than, the processes, strategies, evidentiary
standards, or other factors used in applying the medical
necessity criteria and each nonquantitative treatment

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limitation to medical and surgical benefits within the
corresponding classification of benefits; at a minimum,
the results of the analysis shall:
(A) identify the factors used to determine that a
nonquantitative treatment limitation applies to a
benefit, including factors that were considered but
rejected;
(B) identify and define the specific evidentiary
standards used to define the factors and any other
evidence relied upon in designing each nonquantitative
treatment limitation;
(C) provide the comparative analyses, including
the results of the analyses, performed to determine
that the processes and strategies used to design each
nonquantitative treatment limitation, as written, for
mental, emotional, nervous, or substance use disorder
or condition benefits are comparable to, and are
applied no more stringently than, the processes and
strategies used to design each nonquantitative
treatment limitation, as written, for medical and
surgical benefits;
(D) provide the comparative analyses, including
the results of the analyses, performed to determine
that the processes and strategies used to apply each
nonquantitative treatment limitation, in operation,
for mental, emotional, nervous, or substance use

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disorder or condition benefits are comparable to, and
applied no more stringently than, the processes or
strategies used to apply each nonquantitative
treatment limitation, in operation, for medical and
surgical benefits; and
(E) disclose the specific findings and conclusions
reached by the insurer that the results of the
analyses described in subparagraphs (C) and (D)
indicate that the insurer is in compliance with this
Section and the Mental Health Parity and Addiction
Equity Act of 2008 and its implementing regulations,
which include includes 42 CFR Parts 438, 440, and 457
and 45 CFR 146.136 and any other related federal
regulations found in the Code of Federal Regulations.
(7) Any other information necessary to clarify data
provided in accordance with this Section requested by the
Director, including information that may be proprietary or
have commercial value, under the requirements of Section
30 of the Viatical Settlements Act of 2009.
(l) An insurer that amends, delivers, issues, or renews a
group or individual policy of accident and health insurance or
a qualified health plan offered through the health insurance
marketplace in this State providing coverage for hospital or
medical treatment and for the treatment of mental, emotional,
nervous, or substance use disorders or conditions on or after
January 1, 2019 (the effective date of Public Act 100-1024)

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shall, in advance of the plan year, make available to the
Department or, with respect to medical assistance, the
Department of Healthcare and Family Services and to all plan
participants and beneficiaries the information required in
subparagraphs (C) through (E) of paragraph (6) of subsection
(k). For plan participants and medical assistance
beneficiaries, the information required in subparagraphs (C)
through (E) of paragraph (6) of subsection (k) shall be made
available on a publicly available website whose web address is
prominently displayed in plan and managed care organization
informational and marketing materials.
(m) In conjunction with its compliance examination program
conducted in accordance with the Illinois State Auditing Act,
the Auditor General shall undertake a review of compliance by
the Department and the Department of Healthcare and Family
Services with Section 370c and this Section. Any findings
resulting from the review conducted under this Section shall
be included in the applicable State agency's compliance
examination report. Each compliance examination report shall
be issued in accordance with Section 3-14 of the Illinois
State Auditing Act. A copy of each report shall also be
delivered to the head of the applicable State agency and
posted on the Auditor General's website.
(Source: P.A. 103-94, eff. 1-1-24; 103-105, eff. 6-27-23;
103-605, eff. 7-1-24; 104-334, eff. 8-15-25.)

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ARTICLE 200.
Section 200-5. The Illinois Public Aid Code is amended by
changing Sections 5F-10, 5F-15, and 5F-35 as follows:
(305 ILCS 5/5F-10)
Sec. 5F-10. Scope. This Article applies to policies and
contracts amended, delivered, issued, or renewed on or after
the effective date of this amendatory Act of the 98th General
Assembly for the nursing home component of the
Medicare-Medicaid Alignment Initiative and the Managed
Long-Term Services and Support Program, a fully integrated
dual eligible special needs plan, or any managed care plan for
persons who are dually eligible for Medicare and Medicaid.
This Article does not diminish a managed care organization's
duties and responsibilities under other federal or State laws
or rules adopted under those laws and the 3-way
Medicare-Medicaid Alignment Initiative contract and the
Managed Long-Term Services and Support Program contract.
(Source: P.A. 98-651, eff. 6-16-14; 99-719, eff. 1-1-17.)
(305 ILCS 5/5F-15)
Sec. 5F-15. Definitions. As used in this Article:
"Appeal" means any of the procedures that deal with the
review of adverse organization determinations on the health
care services the enrollee believes he or she is entitled to

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receive, including delay in providing, arranging for, or
approving the health care services, such that a delay would
adversely affect the health of the enrollee or on any amounts
the enrollee must pay for a service, as defined under 42 CFR
422.566(b). These procedures include reconsiderations by the
managed care organization and, if necessary, an independent
review entity as provided by the Health Carrier External
Review Act, hearings before administrative law judges, review
by the Medicare Appeals Council, and judicial review.
"Demonstration Project" means the nursing home component
of the Medicare-Medicaid Alignment Initiative Demonstration
Project, a fully integrated dual eligible special needs plan,
or any managed care plan for persons who are dually eligible
for Medicare and Medicaid.
"Department" means the Department of Healthcare and Family
Services.
"Enrollee" means an individual who resides in a nursing
home or is qualified to be admitted to a nursing home and is
enrolled with a managed care organization participating in the
Demonstration Project.
"Health care services" means the diagnosis, treatment, and
prevention of disease and includes medication, primary care,
nursing or medical care, mental health treatment, psychiatric
rehabilitation, memory loss services, physical, occupational,
and speech rehabilitation, enhanced care, medical supplies and
equipment and the repair of such equipment, and assistance

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with activities of daily living.
"Managed care organization" or "MCO" means an entity that
meets the definition of health maintenance organization as
defined in the Health Maintenance Organization Act, is
licensed, regulated and in good standing with the Department
of Insurance, and is authorized to participate in the nursing
home component of the Medicare-Medicaid Alignment Initiative
Demonstration Project by a 3-way contract with the Department
of Healthcare and Family Services and the Centers for Medicare
and Medicaid Services.
"Medical professional" means a physician, physician
assistant, or nurse practitioner.
"Medically necessary" means health care services that a
medical professional, exercising prudent clinical judgment,
would provide to a patient for the purpose of preventing,
evaluating, diagnosing, or treating an illness, injury, or
disease or its symptoms, and that are: (i) in accordance with
the generally accepted standards of medical practice; (ii)
clinically appropriate, in terms of type, frequency, extent,
site, and duration, and considered effective for the patient's
illness, injury, or disease; and (iii) not primarily for the
convenience of the patient, a medical professional, other
health care provider, caregiver, family member, or other
interested party.
"Nursing home" means a facility licensed under the Nursing
Home Care Act.

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"Nurse practitioner" means an individual properly licensed
as a nurse practitioner under the Nurse Practice Act.
"Physician" means an individual licensed to practice in
all branches of medicine under the Medical Practice Act of
1987.
"Physician assistant" means an individual properly
licensed under the Physician Assistant Practice Act of 1987.
"Resident" means an enrollee who is receiving personal or
medical care, including, but not limited to, mental health
treatment, psychiatric rehabilitation, physical
rehabilitation, and assistance with activities of daily
living, from a nursing home.
"RAI Manual" means the most recent Resident Assessment
Instrument Manual, published by the Centers for Medicare and
Medicaid Services.
"Resident's representative" means a person designated in
writing by a resident to be the resident's representative or
the resident's guardian, as described by the Nursing Home Care
Act.
"SNFist" means a medical professional specializing in the
care of individuals residing in nursing homes employed by or
under contract with an a MCO.
"Transition period" means a period of time immediately
following enrollment into the Demonstration Project or an
enrollee's movement from one managed care organization to
another managed care organization or one care setting to

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another care setting.
(Source: P.A. 98-651, eff. 6-16-14.)
(305 ILCS 5/5F-35)
Sec. 5F-35. Reimbursement. The Department shall provide
each managed care organization with the quarterly
facility-specific RUG-IV nursing component per diem along with
any add-ons for enhanced care services, support component per
diem, and capital component per diem effective for each
nursing home under contract with the managed care
organization.
(Source: P.A. 98-651, eff. 6-16-14.)
ARTICLE 210.
Section 210-5. The Nursing Home Care Act is amended by
adding Article IIIB as follows:
(210 ILCS 45/Art. IIIB heading new)
ARTICLE IIIB. COTTAGE STYLE NURSING HOMES
(210 ILCS 45/3B-100 new)
Sec. 3B-100. Definitions. As used in this Article:
"Clinical support team" (CST) means non-universal team
members who provide support services throughout the campus.
The CST provides support to self-directed or self-managed work

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teams. The CST includes, but is not limited to, the
Administrator, Director of Nursing, Assistant Director of
Nursing, and Minimum Data Set nurse.
"Cottage style" or "cottage style facilities" means small,
free-standing, self-contained homes that:
(1) Surround or are adjacent to a central
administration unit.
(2) Provide up to 12 private residents' rooms that are
shared only at the request of a resident to accommodate a
spouse, partner, or family member. A spouse that does not
meet medical criteria for nursing facility placement may
reside in the room assigned to a spouse who is admitted to
the facility and who meets medical criteria for admission.
The facility may charge the spouse who does not meet
medical criteria for room and board, as well as other
services so long as the facility meets all requirements or
cost reporting.
(3) Have a full, accessible private bathroom for each
resident room that contains, at a minimum, a toilet, sink,
and shower.
(4) Have the appearance of a residential dwelling for
both the exterior and the interior.
(5) Have residents' rooms constructed around a
central, communal, family-style open space that includes a
hearth room, dining area, and residential-style kitchen.
The central communal area shall contain a living area

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where residents and staff may socialize, dine, and prepare
food together that, at a minimum, provides a living room
seating area, a dining area large enough for a single
table serving all residents in the home plus 2 staff
members, and an open full kitchen. The communal area may
include a gas fireplace with a fixed, "stay-cool" glass
screen.
(6) Have all residents' room entrances visible from
the central communal area.
(7) Each communal area may not exceed a ratio of one
communal area to 12 resident rooms.
(8) Two cottages may share a centralized kitchen and
laundry, but each may not exceed a ratio of one
kitchen/laundry to 24 resident rooms.
(9) Contains residential-style design approach, scale,
details, and materials throughout the home that are
similar to the typical residential designs and finishes in
the immediate surrounding community and does not contain
or utilize commercial and institutional elements and
products such as a nurse station, medication carts,
hospital or office type fluorescent lighting, acoustical
tile ceilings, institutional-style railings, room
numbering, and labeling and signage that would not
normally be found in a private home setting.
Where rules require specific institutional elements,
every effort shall be made to provide the institutional

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elements in a manner consistent with what might be found
in a new private home in the community (such as
residential wall sconces used for required nurse call
lights).
(10) Have outdoor space that:
(A) allows residents to ambulate, with or without
assistive devices such as wheelchairs or walkers;
(B) signals staff wirelessly when someone enters
the outdoor space from the cottage style home;
(C) is partially covered to protect from sun and
elements under the covered area; and
(D) provides for outdoor activities.
(11) Utilize a wireless alert or call system. The
system shall also include, for residents who have been
care planned to be at risk for wandering or elopement,
location bracelets that permit residents to signal for
assistance and enable staff to locate residents. Wired
call or alert systems and overhead paging are not
permitted.
(12) Utilize a wireless communication and notification
system for staff. The system shall provide a means for
notification of staff both in the home and in other homes
or other areas of the facility occupied by other staff.
(13) Contain ample natural light in each habitable
space provided through exterior windows and other means,
with window areas, exclusive of skylights and

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clerestories, being a minimum of 10% of the area of the
room.
(14) Have built-in safety features (such as magnetic
locks on cabinets with chemicals or knives) to allow all
areas of the house, including the kitchen and any staff
office, to be accessible to the residents during the
majority of the day and night.
(15) Provide self-directed care for residents through
the establishment of self-managed or self-directed work
teams consisting of certified nursing assistants.
(16) Prepare and cook at least 80% of resident meals
in the cottage style home. Nothing in this item (16)
prohibits the consumption of foods that are:
(A) prepared outside the cottage style home by
family, acquaintances, or social organizations such as
churches;
(B) grown in or on the grounds of the cottage style
home by residents or staff; or
(C) prepared by local retail eating establishments
that are licensed or inspected based on local, State,
or federal laws.
(17) Train all staff involved in the operation of the
project in the philosophy, operations, and skills required
to implement and maintain self-directed care,
self-directed or self-managed work teams, a
non-institutional approach to life and care in long-term

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care, appropriate safety and emergency skills, and other
elements required for successful operations and outcomes
of the project.
(18) Are designed to be fully accessible for persons
with disabilities.
(19) Have overhead lift tracks that run from the bed
into the bathroom in at least 30% of resident rooms.
(20) Have at least one lift motor for each cottage
style home.
(21) Have separate slings for each resident in the
facility who requires a lift.
(22) Are not connected to, or share, any area that
would not typically be connected or shared between private
homes in the surrounding community (such as a driveway).
(23) Provide the necessary care and services to attain
or maintain the highest practicable physical, mental, and
psychological well-being of the resident, in accordance
with each resident's comprehensive resident care plan.
(24) Maintain a staffing plan compliant with the
minimum direct care staffing ratios required by this Act,
the Illinois Administrative Code, and any other applicable
State or federal law.
(25) Maintain all professional licensure for staff and
employees in accordance with applicable State laws,
including, but not limited to, Department of Financial and
Professional Regulation requirements.

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(26) Comply with any applicable State and federal
consent decrees.
(27) Obtain proof and documentation of federal
approval by the Centers for Medicare and Medicaid
Services.
"Home" means each discrete cottage style unit housing up
to 12 private residents' rooms.
"Person-directed care" means a holistic model that takes
into consideration each resident's physical, mental, and
social needs in the development of a care and treatment plan
and the delivery of services that is driven to the greatest
extent possible by resident choice, as opposed to an
institutional medical model that is schedule and task driven.
"Self-managed or self-directed work team" means the
universal workers assigned to a specific cottage style home
and who determine, plan, and manage day-to-day activities in
the house with little or no direct supervision.
"Food safety" means a method of ensuring safe preparation
and delivery of food for and to residents.
"Family-style dining" means residential-style dining, in
which all food is placed in serving bowls, platters, and
similar residential serving dishes on the table, residents and
staff dine together, and residents are encouraged to serve
themselves or serve themselves with help from staff.
"Universal or flexible worker" means a certified nursing
assistant who has received additional training in the areas of

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dietary, housekeeping, activities, and laundry and is a member
of the self-managed or self-directed work team.
(210 ILCS 45/3B-105 new)
Sec. 3B-105. Intent. This Article creates a framework that
encourages the construction and operation of skilled nursing
facilities that are consistent with State and federal laws and
referred to as "cottage style". The cottage style model is a
facility model resulting in a residential-style physical plant
and specific principles of staff interaction. The cottage
style model utilizes small, free-standing, self-contained
homes. A single cottage consists of up to 12 private rooms,
each with full bathrooms. Two cottages may share a common
kitchen and laundry but the maximum ratio of 1 kitchen and
laundry per 24 rooms must be maintained. The residents' rooms
are constructed around a central, communal, family-style open
space that includes a hearth room and dining area. All
residents' room entrances are visible from the central
communal area. The maximum ratio of one communal area per 12
rooms must be maintained. Each home is built to blend
architecturally with neighboring homes.
(210 ILCS 45/3B-110 new)
Sec. 3B-110. Applicability. Nursing homes that meet the
requirements of this Article to be designated as a cottage
style nursing home are still subject to all requirements of

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this Act, administrative rules, and applicable State or
federal laws. All requirements of this Article are additional
requirements necessary to be designated as cottage style as
defined in Section 3B-100.
(210 ILCS 45/3B-115 new)
Sec. 3B-115. License designation. During the initial
licensure survey required under Section 3-109 of this Act, the
Department must also review compliance with this Article. The
Department must indicate, on licenses issued under this Act,
"cottage style" for nursing homes that meet the requirements
of this Article.
(210 ILCS 45/3B-120 new)
Sec. 3B-120. Staff Training.
(a) In addition to any State or federal training
requirements pertaining to long-term care facilities, each
certified nursing assistant (CNA) working in a cottage style
home shall complete the following 40 hours of training, to
include, but not be limited to:
(1) Cottage Style Model v. Traditional Model, a
minimum of 2 hours covering at least the following topics:
(A) Meaningful Engagement. Development of, and
appreciation for, activities designed to meet the
individual's personal preferences and needs.
(B) Organizational Culture Change.

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(2) Universal or Flexible Worker, a minimum of 2 hours
covering at least the following topics:
(A) Concept.
(B) Responsibilities of the Worker.
(3) Person-Directed Care, a minimum of 2 hours
covering at least the following topics:
(A) Concepts and Relationship Building.
(B) Execution. How elder preferences shape
workflow.
(4) Self-Managed or Self-Directed Work Team, a minimum
of 4 hours covering at least the following topics:
(A) Concept.
(B) Responsibilities.
(C) Conflict Resolution and Learning Circles.
(5) Food Safety, a minimum of 22 hours covering at
least the following topics:
(A) Safety.
(B) Contamination.
(C) Allergies.
(D) Therapeutic Diets.
(E) Thickening Agents.
(F) Food Preparation.
(G) Family Style Dining.
(H) Cottage Equipment Use. Appliance usage and
safety.
(6) Emergency Situations and Evacuation, a minimum of

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2 hours covering at least the following topics:
(A) Fire Drills.
(B) Tornado Drills.
(C) Disaster Drills.
(D) Evacuation.
(E) Environmental Policy.
(7) Cottage Orientation, a minimum of 2 hours covering
at least the following topics:
(A) Phone System.
(B) Call System.
(C) Cleaning Supply Storage.
(D) Cleaning Supply Usage.
(E) Workplace Organization.
(8) Communication, a minimum of 2 hours covering at
least the following topics:
(A) Communication Skills.
(B) Coaching Skills.
(C) Accountability.
(D) Support.
(9) Observation Skills, a minimum of 2 hours covering
at least the following topics:
(A) How to obtain a history from family.
(B) How to modify a care plan.
(C) How to identify a resident's change in
condition.
(b) Upon opening and for the first 90 days of continuous

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operation of a cottage style home, all CNAs working in that
home shall complete all of the required training listed in
subsection (a) prior to providing services in the cottage
style home.
(c) After a cottage style home has been in continuous
operation servicing residents for at least 90 days, each CNA
assigned to the cottage style home for the first time, and who
has not been trained in accordance with subsections (a) and
(b), shall complete the following 16-hour training schedule
before working with residents:
(1) Cottage Style Model v. Traditional Model, a
minimum of 1.5 hours.
(2) Universal or Flexible Worker, a minimum of 1.5
hours.
(3) Person-Directed Care, a minimum of 3 hours.
(4) Self-Managed or Self-Directed Work Team, a minimum
of 3 hours.
(5) Food Safety, a minimum of 3 hours.
(6) Family Style Dining, a minimum of one hour.
(7) Emergency Situations and Evacuations, a minimum of
one hour.
(8) Cottage Equipment Use, a minimum of one hour.
(9) Cottage Orientation, a minimum of one hour.
Following the 16-hour training the CNA shall complete the
remaining 24 hours of training listed in subsection (a) within
90 days.

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(d) All shared common staff shall undergo the following
training within 45 days of the opening of the first cottage
style home:
(1) Cottage Style Model v. Traditional Model, a
minimum of 1.5 hours.
(2) Clinical Support Team, a minimum of one hour.
(3) Universal or Flexible Worker, a minimum of one
hour.
(4) Self-Managed or Self-Directed Work Team, a minimum
of 3 hours.
(5) Person-Directed Care, a minimum of 3 hours.
(6) Team Communication, a minimum of one hour.
(7) Learning Circles, a minimum of one hour.
(8) Understanding Aging in the Elderly, a minimum of
one hour.
(9) Cottage Systems, a minimum of 2 hours.
(e) Each facility seeking designation as a cottage style
facility shall provide to the Department a syllabus, a list of
required reference and study materials, and a proposed
curriculum of training as required under this Section. As used
in this Section, "curriculum" means a detailed study guide
that states the learning objectives and provides information
or materials designed to impart to the student or trainee the
necessary skills, knowledge, or ability required under the
learning objectives.
(f) Facilities must keep all trainings current with all

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changes in best practices and local, State, and federal laws,
rules, regulations, and guidance.
(210 ILCS 45/3B-125 new)
Sec. 3B-125. Implementation. The Department may adopt
administrative rules to implement any part of this Article;
however, all provisions of this Article are fully effective
upon taking effect even if administrative rules have not been
adopted.
Section 210-10. The Illinois Public Aid Code is amended by
adding Section 5-5.2a as follows:
(305 ILCS 5/5-5.2a new)
Sec. 5-5.2a. Cottage style nursing home reimbursement
adjustment.
(a) As used in this Section, "cottage style nursing home"
means a nursing home meeting the requirements under Article
IIIB of the Nursing Home Care Act.
(b) Subject to any necessary federal approval, for dates
of service on and after July 1, 2027, the Department shall
reimburse cottage style nursing homes with a per diem add-on
of at least $50.
(c) This per diem add-on amount is in addition to all
amounts reimbursed to a nursing home under this Code. To
account for the unique person-directed care model in cottage

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style nursing homes, the Department may increase the initial
default rates of a new cottage style nursing home until data
required to calculate those rates are available.
ARTICLE 215.
Section 215-5. The Illinois Public Aid Code is amended by
changing Section 5-5e.1 as follows:
(305 ILCS 5/5-5e.1)
Sec. 5-5e.1. Safety-Net Hospitals.
(a) A Safety-Net Hospital is an Illinois hospital that:
(1) is licensed by the Department of Public Health as
a general acute care or pediatric hospital; and
(2) is a disproportionate share hospital, as described
in Section 1923 of the federal Social Security Act, as
determined by the Department; and
(3) meets one of the following:
(A) has a MIUR of at least 40% and a charity
percent of at least 4%; or
(B) has a MIUR of at least 50%.
(b) Definitions. As used in this Section:
(1) "Charity percent" means the ratio of (i) the
hospital's charity charges for services provided to
individuals without health insurance or another source of
third party coverage to (ii) the Illinois total hospital

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charges, each as reported on the hospital's OBRA form.
(2) "MIUR" means Medicaid Inpatient Utilization Rate
and is defined as a fraction, the numerator of which is the
number of a hospital's inpatient days provided in the
hospital's fiscal year ending 3 years prior to the rate
year, to patients who, for such days, were eligible for
Medicaid under Title XIX of the federal Social Security
Act, 42 USC 1396a et seq., excluding those persons
eligible for medical assistance pursuant to 42 U.S.C.
1396a(a)(10)(A)(i)(VIII) as set forth in paragraph 18 of
Section 5-2 of this Article, and the denominator of which
is the total number of the hospital's inpatient days in
that same period, excluding those persons eligible for
medical assistance pursuant to 42 U.S.C.
1396a(a)(10)(A)(i)(VIII) as set forth in paragraph 18 of
Section 5-2 of this Article.
(3) "OBRA form" means form HFS-3834, OBRA '93 data
collection form, for the rate year.
(4) "Rate year" means the 12-month period beginning on
October 1.
(c) Beginning July 1, 2012 and ending on December 31, 2028
2026, a hospital that would have qualified for the rate year
beginning October 1, 2011 or October 1, 2012 shall be a
Safety-Net Hospital.
(c-5) Beginning July 1, 2020 and ending on December 31,
2028 2026, a hospital that would have qualified for the rate

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year beginning October 1, 2020 and was designated a federal
rural referral center under 42 CFR 412.96 as of October 1, 2020
shall be a Safety-Net Hospital.
(d) No later than August 15 preceding the rate year, each
hospital shall submit the OBRA form to the Department. Prior
to October 1, the Department shall notify each hospital
whether it has qualified as a Safety-Net Hospital.
(e) The Department may promulgate rules in order to
implement this Section.
(f) Nothing in this Section shall be construed as limiting
the ability of the Department to include the Safety-Net
Hospitals in the hospital rate reform mandated by Section
14-11 of this Code and implemented under Section 14-12 of this
Code and by administrative rulemaking.
(Source: P.A. 101-650, eff. 7-7-20; 101-669, eff. 4-2-21;
102-886, eff. 5-17-22.)
ARTICLE 220.
Section 220-5. The Illinois Administrative Procedure Act
is amended by adding Section 5-45.72 as follows:
(5 ILCS 100/5-45.72 new)
Sec. 5-45.72. Emergency rulemaking; Department of
Healthcare and Family Services. In order to provide for the
expeditious and timely implementation of the federal Medicaid

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provisions contained in Public Law 119-21, including all
corresponding federal regulations and requirements issued by
the federal Centers for Medicare and Medicaid Services, the
Department of Healthcare and Family Services may adopt
emergency rules during fiscal year 2027. Emergency rulemaking
authority will pertain to changes in Public Law 119-21 with
implementation dates on or before January 1, 2027, which are
addressed in this amendatory Act of the 104th General
Assembly. During the 12-month period in which this Section is
in effect, the 24-month limitation on the adoption of
emergency rules does not apply to the rules adopted under this
subsection if such an amendment is due to subsequent federal
guidance or other federal requirements pertaining to changes
in federal law or regulation. The adoption of emergency rules
authorized by this Section shall be deemed to be necessary for
the public interest, safety, and welfare.
This Section is repealed one year after the effective date
of this amendatory Act of the 104th General Assembly.
Section 220-10. The Illinois Public Aid Code is amended by
changing Sections 1-11, 5-2, 5-2.1d, 11-4, 11-5.1, and 11-5.4
as follows:
(305 ILCS 5/1-11)
Sec. 1-11. Citizenship. To the extent not otherwise
provided in this Code or federal law, all clients who receive

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cash or medical assistance under Article III, IV, V, or VI of
this Code must meet the citizenship requirements as
established in this Section. To be eligible for assistance an
individual, who is otherwise eligible, must be either a United
States citizen or included in one of the following categories
of non-citizens:
(1) United States veterans honorably discharged and
persons on active military duty, and the spouse and
unmarried dependent children of these persons;
(2) Refugees under Section 207 of the Immigration and
Nationality Act;
(3) Asylees under Section 208 of the Immigration and
Nationality Act;
(4) Persons for whom deportation has been withheld
under Section 243(h) of the Immigration and Nationality
Act;
(5) Persons granted conditional entry under Section
203(a)(7) of the Immigration and Nationality Act as in
effect prior to April 1, 1980;
(6) Persons lawfully admitted for permanent residence
under the Immigration and Nationality Act;
(7) Parolees, for at least one year, under Section
212(d)(5) of the Immigration and Nationality Act;
(8) Nationals of Cuba or Haiti admitted on or after
April 21, 1980;
(9) Amerasians from Vietnam, and their close family

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members, admitted through the Orderly Departure Program
beginning on March 20, 1988;
(10) Persons identified by the federal Office of
Refugee Resettlement (ORR) as victims of trafficking;
(11) Persons legally residing in the United States who
were members of a Hmong or Highland Laotian tribe when the
tribe helped United States personnel by taking part in a
military or rescue operation during the Vietnam era
(between August 5, 1965 and May 7, 1975); this also
includes the person's spouse, a widow or widower who has
not remarried, and unmarried dependent children;
(12) American Indians born in Canada under Section 289
of the Immigration and Nationality Act and members of an
Indian tribe as defined in Section 4e of the Indian
Self-Determination and Education Assistance Act;
(13) Persons who are a spouse, widow, or child of a
U.S. citizen or a spouse or child of a legal permanent
resident (LPR) who have been battered or subjected to
extreme cruelty by the U.S. citizen or LPR or a member of
that relative's family who lived with them, who no longer
live with the abuser or plan to live separately within one
month of receipt of assistance and whose need for
assistance is due, at least in part, to the abuse; and
(14) Persons who are foreign-born victims of
trafficking, torture, or other serious crimes as defined
in Section 2-19 of this Code.

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Those persons who are in the categories set forth in
paragraphs subdivisions (6) and (7) of this Section, who enter
the United States on or after August 22, 1996, shall not be
eligible for 5 years beginning on the date the person entered
the United States.
The Illinois Department may, by rule, cover prenatal care
or emergency medical care for non-citizens who are not
otherwise eligible under this Section. Local governmental
units which do not receive State funds may impose their own
citizenship requirements and are authorized to provide any
benefits and impose any citizenship requirements as are
allowed under the Personal Responsibility and Work Opportunity
Reconciliation Act of 1996 (P.L. 104-193).
In order to implement the federal Medicaid provisions
contained in Public Law 119-21, and notwithstanding any other
provision of this Section, any category of non-citizens or
part thereof listed in paragraphs (1) through (14) of this
Section shall not be eligible for medical assistance under
Article V of this Code to the extent Public Law 119-21 and any
corresponding federal regulations or requirements issued by
the federal Centers for Medicare and Medicaid Services
excludes such category of non-citizens or part thereof from
eligibility, federal financial participation, or other federal
funding. This Section shall not require any category of
non-citizens or part thereof to be funded at state-only cost
under Article V of this Code, unless otherwise provided by

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State law. The Department shall amend 89 Ill. Adm. Code
120.310 to conform to the provisions of this paragraph
effective October 1, 2026.
(Source: P.A. 99-870, eff. 8-22-16.)
(305 ILCS 5/5-2) (from Ch. 23, par. 5-2)
Sec. 5-2. Classes of persons eligible. Medical assistance
under this Article shall be available to any of the following
classes of persons in respect to whom a plan for coverage has
been submitted to the Governor by the Illinois Department and
approved by him. If changes made in this Section 5-2 require
federal approval, they shall not take effect until such
approval has been received:
1. Recipients of basic maintenance grants under
Articles III and IV.
2. Beginning January 1, 2014, persons otherwise
eligible for basic maintenance under Article III,
excluding any eligibility requirements that are
inconsistent with any federal law or federal regulation,
as interpreted by the U.S. Department of Health and Human
Services, but who fail to qualify thereunder on the basis
of need, and who have insufficient income and resources to
meet the costs of necessary medical care, including, but
not limited to, the following:
(a) All persons otherwise eligible for basic
maintenance under Article III but who fail to qualify

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under that Article on the basis of need and who meet
either of the following requirements:
(i) their income, as determined by the
Illinois Department in accordance with any federal
requirements, is equal to or less than 100% of the
federal poverty level; or
(ii) their income, after the deduction of
costs incurred for medical care and for other
types of remedial care, is equal to or less than
100% of the federal poverty level.
(b) (Blank).
3. (Blank).
4. Persons not eligible under any of the preceding
paragraphs who fall sick, are injured, or die, not having
sufficient money, property or other resources to meet the
costs of necessary medical care or funeral and burial
expenses.
5.(a) Beginning January 1, 2020, individuals during
pregnancy and during the 12-month period beginning on the
last day of the pregnancy, together with their infants,
whose income is at or below 200% of the federal poverty
level. Until September 30, 2019, or sooner if the
maintenance of effort requirements under the Patient
Protection and Affordable Care Act are eliminated or may
be waived before then, individuals during pregnancy and
during the 12-month period beginning on the last day of

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the pregnancy, whose countable monthly income, after the
deduction of costs incurred for medical care and for other
types of remedial care as specified in administrative
rule, is equal to or less than the Medical Assistance-No
Grant(C) (MANG(C)) Income Standard in effect on April 1,
2013 as set forth in administrative rule.
(b) The plan for coverage shall provide ambulatory
prenatal care to pregnant individuals during a presumptive
eligibility period and establish an income eligibility
standard that is equal to 200% of the federal poverty
level, provided that costs incurred for medical care are
not taken into account in determining such income
eligibility.
(c) The Illinois Department may conduct a
demonstration in at least one county that will provide
medical assistance to pregnant individuals together with
their infants and children up to one year of age, where the
income eligibility standard is set up to 185% of the
nonfarm income official poverty line, as defined by the
federal Office of Management and Budget. The Illinois
Department shall seek and obtain necessary authorization
provided under federal law to implement such a
demonstration. Such demonstration may establish resource
standards that are not more restrictive than those
established under Article IV of this Code.
6. (a) Subject to federal approval, children younger

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than age 19 when countable income is at or below 313% of
the federal poverty level, as determined by the Department
and in accordance with all applicable federal
requirements. The Department is authorized to adopt
emergency rules to implement the changes made to this
paragraph by Public Act 102-43. Until September 30, 2019,
or sooner if the maintenance of effort requirements under
the Patient Protection and Affordable Care Act are
eliminated or may be waived before then, children younger
than age 19 whose countable monthly income, after the
deduction of costs incurred for medical care and for other
types of remedial care as specified in administrative
rule, is equal to or less than the Medical Assistance-No
Grant(C) (MANG(C)) Income Standard in effect on April 1,
2013 as set forth in administrative rule.
(b) Children and youth who are under temporary custody
or guardianship of the Department of Children and Family
Services or who receive financial assistance in support of
an adoption or guardianship placement from the Department
of Children and Family Services.
7. (Blank).
8. As required under federal law, persons who are
eligible for Transitional Medical Assistance as a result
of an increase in earnings or child or spousal support
received. The plan for coverage for this class of persons
shall:

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(a) extend the medical assistance coverage to the
extent required by federal law; and
(b) offer persons who have initially received 6
months of the coverage provided in paragraph (a)
above, the option of receiving an additional 6 months
of coverage, subject to the following:
(i) such coverage shall be pursuant to
provisions of the federal Social Security Act;
(ii) such coverage shall include all services
covered under Illinois' State Medicaid Plan;
(iii) no premium shall be charged for such
coverage; and
(iv) such coverage shall be suspended in the
event of a person's failure without good cause to
file in a timely fashion reports required for this
coverage under the Social Security Act and
coverage shall be reinstated upon the filing of
such reports if the person remains otherwise
eligible.
9. Persons with acquired immunodeficiency syndrome
(AIDS) or with AIDS-related conditions with respect to
whom there has been a determination that but for home or
community-based services such individuals would require
the level of care provided in an inpatient hospital,
skilled nursing facility or intermediate care facility the
cost of which is reimbursed under this Article. Assistance

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shall be provided to such persons to the maximum extent
permitted under Title XIX of the Federal Social Security
Act.
10. Participants in the long-term care insurance
partnership program established under the Illinois
Long-Term Care Partnership Program Act who meet the
qualifications for protection of resources described in
Section 15 of that Act.
11. Persons with disabilities who are employed and
eligible for Medicaid, pursuant to Section
1902(a)(10)(A)(ii)(xv) of the Social Security Act, and,
subject to federal approval, persons with a medically
improved disability who are employed and eligible for
Medicaid pursuant to Section 1902(a)(10)(A)(ii)(xvi) of
the Social Security Act, as provided by the Illinois
Department by rule. In establishing eligibility standards
under this paragraph 11, the Department shall, subject to
federal approval:
(a) set the income eligibility standard at not
lower than 350% of the federal poverty level;
(b) exempt retirement accounts that the person
cannot access without penalty before the age of 59
1/2, and medical savings accounts established pursuant
to 26 U.S.C. 220;
(c) allow non-exempt assets up to $25,000 as to
those assets accumulated during periods of eligibility

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under this paragraph 11; and
(d) continue to apply subparagraphs (b) and (c) in
determining the eligibility of the person under this
Article even if the person loses eligibility under
this paragraph 11.
12. Subject to federal approval, persons who are
eligible for medical assistance coverage under applicable
provisions of the federal Social Security Act and the
federal Breast and Cervical Cancer Prevention and
Treatment Act of 2000. Those eligible persons are defined
to include, but not be limited to, the following persons:
(1) persons who have been screened for breast or
cervical cancer under the U.S. Centers for Disease
Control and Prevention Breast and Cervical Cancer
Program established under Title XV of the federal
Public Health Service Act in accordance with the
requirements of Section 1504 of that Act as
administered by the Illinois Department of Public
Health; and
(2) persons whose screenings under the above
program were funded in whole or in part by funds
appropriated to the Illinois Department of Public
Health for breast or cervical cancer screening.
"Medical assistance" under this paragraph 12 shall be
identical to the benefits provided under the State's
approved plan under Title XIX of the Social Security Act.

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The Department must request federal approval of the
coverage under this paragraph 12 within 30 days after July
3, 2001 (the effective date of Public Act 92-47).
In addition to the persons who are eligible for
medical assistance pursuant to subparagraphs (1) and (2)
of this paragraph 12, and to be paid from funds
appropriated to the Department for its medical programs,
any uninsured person as defined by the Department in rules
residing in Illinois who is younger than 65 years of age,
who has been screened for breast and cervical cancer in
accordance with standards and procedures adopted by the
Department of Public Health for screening, and who is
referred to the Department by the Department of Public
Health as being in need of treatment for breast or
cervical cancer is eligible for medical assistance
benefits that are consistent with the benefits provided to
those persons described in subparagraphs (1) and (2).
Medical assistance coverage for the persons who are
eligible under the preceding sentence is not dependent on
federal approval, but federal moneys may be used to pay
for services provided under that coverage upon federal
approval.
13. Subject to appropriation and to federal approval,
persons living with HIV/AIDS who are not otherwise
eligible under this Article and who qualify for services
covered under Section 5-5.04 as provided by the Illinois

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Department by rule.
14. Subject to the availability of funds for this
purpose, the Department may provide coverage under this
Article to persons who
(a) reside in Illinois;
(b) are not eligible under any of the preceding
paragraphs of this Section;
(c) meet the income guidelines of paragraph 2(a)
of this Section; and
(d) meet one of the following conditions:
(i) have filed an application for asylum
status under 8 U.S.C. 1158 that is pending with
the appropriate federal agency or have a pending
appeal of such an application before a court of
competent jurisdiction and are represented either
by counsel or by an advocate accredited by the
appropriate federal agency and employed by a
not-for-profit organization in regard to that
application or appeal;
(ii) are receiving services through a
federally funded torture treatment center;
(iii) have filed a pending application for T
nonimmigrant status pursuant to 8 U.S.C.
1101(a)(15)(T);
(iv) have filed a pending application for U
nonimmigrant status pursuant to 8 U.S.C.

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1101(a)(15)(U); or
(v) have filed as a derivative family member
or are included in the application for item (i),
(iii), or (iv) as provided by Department rule.
Medical coverage under this paragraph 14 may be
provided for up to 24 continuous months from the initial
eligibility date so long as an individual continues to
satisfy the criteria of this paragraph 14. If an
individual has an application or appeal pending regarding
an application for asylum, T nonimmigrant status, or U
nonimmigrant status before the appropriate federal agency
for such applications or appeals, eligibility under this
paragraph 14 may be extended until a final decision is
rendered with respect to the application or appeal, except
that an individual who is approved for a U visa continues
to qualify for medical coverage under this paragraph 14 as
long as the individual meets all other eligibility
criteria. The Department shall adopt rules governing the
implementation of this paragraph 14.
15. Family Care Eligibility.
(a) On and after July 1, 2012, a parent or other
caretaker relative who is 19 years of age or older when
countable income is at or below 133% of the federal
poverty level. A person may not spend down to become
eligible under this paragraph 15.
(b) Eligibility shall be reviewed annually.

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(c) (Blank).
(d) (Blank).
(e) (Blank).
(f) (Blank).
(g) (Blank).
(h) (Blank).
(i) Following termination of an individual's
coverage under this paragraph 15, the individual must
be determined eligible before the person can be
re-enrolled.
16. Subject to appropriation, uninsured persons who
are not otherwise eligible under this Section who have
been certified and referred by the Department of Public
Health as having been screened and found to need
diagnostic evaluation or treatment, or both diagnostic
evaluation and treatment, for prostate or testicular
cancer. For the purposes of this paragraph 16, uninsured
persons are those who do not have creditable coverage, as
defined under the Health Insurance Portability and
Accountability Act, or have otherwise exhausted any
insurance benefits they may have had, for prostate or
testicular cancer diagnostic evaluation or treatment, or
both diagnostic evaluation and treatment. To be eligible,
a person must furnish a Social Security number. A person's
assets are exempt from consideration in determining
eligibility under this paragraph 16. Such persons shall be

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eligible for medical assistance under this paragraph 16
for so long as they need treatment for the cancer. A person
shall be considered to need treatment if, in the opinion
of the person's treating physician, the person requires
therapy directed toward cure or palliation of prostate or
testicular cancer, including recurrent metastatic cancer
that is a known or presumed complication of prostate or
testicular cancer and complications resulting from the
treatment modalities themselves. Persons who require only
routine monitoring services are not considered to need
treatment. "Medical assistance" under this paragraph 16
shall be identical to the benefits provided under the
State's approved plan under Title XIX of the Social
Security Act. Notwithstanding any other provision of law,
the Department (i) does not have a claim against the
estate of a deceased recipient of services under this
paragraph 16 and (ii) does not have a lien against any
homestead property or other legal or equitable real
property interest owned by a recipient of services under
this paragraph 16.
17. Persons who, pursuant to a waiver approved by the
Secretary of the U.S. Department of Health and Human
Services, are eligible for medical assistance under Title
XIX or XXI of the federal Social Security Act.
Notwithstanding any other provision of this Code and
consistent with the terms of the approved waiver, the

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Illinois Department, may by rule:
(a) Limit the geographic areas in which the waiver
program operates.
(b) Determine the scope, quantity, duration, and
quality, and the rate and method of reimbursement, of
the medical services to be provided, which may differ
from those for other classes of persons eligible for
assistance under this Article.
(c) Restrict the persons' freedom in choice of
providers.
18. Beginning January 1, 2014, persons aged 19 or
older, but younger than 65, who are not otherwise eligible
for medical assistance under this Section 5-2, who qualify
for medical assistance pursuant to 42 U.S.C.
1396a(a)(10)(A)(i)(VIII) to the extent permitted under
federal law and applicable federal regulations, and who
have income at or below 133% of the federal poverty level
plus 5% for the applicable family size as determined
pursuant to 42 U.S.C. 1396a(e)(14) and applicable federal
regulations. Persons eligible for medical assistance under
this paragraph 18 shall receive coverage for the Health
Benefits Service Package as that term is defined in
subsection (m) of Section 5-1.1 of this Code. If Illinois'
federal medical assistance percentage (FMAP) is reduced
below 90% for persons eligible for medical assistance
under this paragraph 18, eligibility under this paragraph

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18 shall cease no later than the end of the third month
following the month in which the reduction in FMAP takes
effect.
19. Beginning January 1, 2014, as required under 42
U.S.C. 1396a(a)(10)(A)(i)(IX), persons older than age 18
and younger than age 26 who are not otherwise eligible for
medical assistance under paragraphs (1) through (17) of
this Section who (i) were in foster care under the
responsibility of the State on the date of attaining age
18 or on the date of attaining age 21 when a court has
continued wardship for good cause as provided in Section
2-31 of the Juvenile Court Act of 1987 and (ii) received
medical assistance under the Illinois Title XIX State Plan
or waiver of such plan while in foster care.
20. (Blank).
21. Persons who are not otherwise eligible for medical
assistance under this Section who may qualify for medical
assistance pursuant to 42 U.S.C.
1396a(a)(10)(A)(ii)(XXIII) and 42 U.S.C. 1396(ss) for the
duration of any federal or State declared emergency due to
COVID-19. Medical assistance to persons eligible for
medical assistance solely pursuant to this paragraph 21
shall be limited to any in vitro diagnostic product (and
the administration of such product) described in 42 U.S.C.
1396d(a)(3)(B) on or after March 18, 2020, any visit
described in 42 U.S.C. 1396o(a)(2)(G), or any other

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medical assistance that may be federally authorized for
this class of persons. The Department may also cover
treatment of COVID-19 for this class of persons, or any
similar category of uninsured individuals, to the extent
authorized under a federally approved 1115 Waiver or other
federal authority. Notwithstanding the provisions of
Section 1-11 of this Code, due to the nature of the
COVID-19 public health emergency, the Department may cover
and provide the medical assistance described in this
paragraph 21 to noncitizens who would otherwise meet the
eligibility requirements for the class of persons
described in this paragraph 21 for the duration of the
State emergency period.
In implementing the provisions of Public Act 96-20, the
Department is authorized to adopt only those rules necessary,
including emergency rules. Nothing in Public Act 96-20 permits
the Department to adopt rules or issue a decision that expands
eligibility for the FamilyCare Program to a person whose
income exceeds 185% of the Federal Poverty Level as determined
from time to time by the U.S. Department of Health and Human
Services, unless the Department is provided with express
statutory authority.
The eligibility of any such person for medical assistance
under this Article is not affected by the payment of any grant
under the Senior Citizens and Persons with Disabilities
Property Tax Relief Act or any distributions or items of

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income described under subparagraph (X) of paragraph (2) of
subsection (a) of Section 203 of the Illinois Income Tax Act.
The Department shall by rule establish the amounts of
assets to be disregarded in determining eligibility for
medical assistance, which shall at a minimum equal the amounts
to be disregarded under the Federal Supplemental Security
Income Program. The amount of assets of a single person to be
disregarded shall not be less than $2,000, and the amount of
assets of a married couple to be disregarded shall not be less
than $3,000.
To the extent permitted under federal law, any person
found guilty of a second violation of Article VIIIA shall be
ineligible for medical assistance under this Article, as
provided in Section 8A-8.
The eligibility of any person for medical assistance under
this Article shall not be affected by the receipt by the person
of donations or benefits from fundraisers held for the person
in cases of serious illness, as long as neither the person nor
members of the person's family have actual control over the
donations or benefits or the disbursement of the donations or
benefits.
Notwithstanding any other provision of this Code, if the
United States Supreme Court holds Title II, Subtitle A,
Section 2001(a) of Public Law 111-148 to be unconstitutional,
or if a holding of Public Law 111-148 makes Medicaid
eligibility allowed under Section 2001(a) inoperable, the

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State or a unit of local government shall be prohibited from
enrolling individuals in the Medical Assistance Program as the
result of federal approval of a State Medicaid waiver on or
after June 14, 2012 (the effective date of Public Act 97-687),
and any individuals enrolled in the Medical Assistance Program
pursuant to eligibility permitted as a result of such a State
Medicaid waiver shall become immediately ineligible.
Notwithstanding any other provision of this Code, if an
Act of Congress that becomes a Public Law eliminates Section
2001(a) of Public Law 111-148, the State or a unit of local
government shall be prohibited from enrolling individuals in
the Medical Assistance Program as the result of federal
approval of a State Medicaid waiver on or after June 14, 2012
(the effective date of Public Act 97-687), and any individuals
enrolled in the Medical Assistance Program pursuant to
eligibility permitted as a result of such a State Medicaid
waiver shall become immediately ineligible.
Effective October 1, 2013, the determination of
eligibility of persons who qualify under paragraphs 5, 6, 8,
15, 17, and 18 of this Section shall comply with the
requirements of 42 U.S.C. 1396a(e)(14) and applicable federal
regulations.
The Department of Healthcare and Family Services, the
Department of Human Services, and the Illinois health
insurance marketplace shall work cooperatively to assist
persons who would otherwise lose health benefits as a result

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of changes made under Public Act 98-104 to transition to other
health insurance coverage.
(Source: P.A. 104-9, eff. 1-1-26.)
(305 ILCS 5/5-2.1d)
Sec. 5-2.1d. Retroactive eligibility. Subject to federal
approval and in accordance with applicable federal law and
requirements, an An applicant for medical assistance may be
eligible for up to 3 months prior to the date of application if
the person would have been eligible for medical assistance at
the time he or she received the services if he or she had
applied, regardless of whether the individual is alive when
the application for medical assistance is made. In determining
financial eligibility for medical assistance for retroactive
months, the Department shall consider the amount of income and
resources and exemptions available to a person as of the first
day of each of the backdated months for which eligibility is
sought. The Department shall, by rule, establish the duration
of retroactive eligibility, which shall at a minimum equal the
duration of eligibility for federal matching funds.
(Source: P.A. 97-689, eff. 6-14-12.)
(305 ILCS 5/11-4) (from Ch. 23, par. 11-4)
Sec. 11-4. Applications; assistance in making
applications. An initial application for public assistance
shall be deemed an application for all such benefits to which

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any person may be entitled except to the extent that the
applicant expressly declines in writing to apply for
particular benefits. A redetermination of eligibility shall
occur at least annually or for any other periodic time period
established by the Department by rule that is necessary to
implement the federal Medicaid provisions contained in Public
Law 119-21 and any corresponding federal regulations or
requirements issued by the federal Centers for Medicare and
Medicaid Services. A redetermination The redetermination is an
annual redetermination of eligibility is for of current
benefits and is not an initial application. The Illinois
Department shall provide information in writing about all
benefits provided under this Code to any person seeking public
assistance. The Illinois Department shall also provide
information in writing and orally to all applicants about an
election to have financial aid deposited directly in a
recipient's savings account or checking account or in any
electronic benefits account or accounts as provided in Section
11-3.1, to the extent that those elections are actually
available, including information on any programs administered
by the State Treasurer to facilitate or encourage the
distribution of financial aid by direct deposit or electronic
benefits transfer. The Illinois Department shall determine the
applicant's eligibility for cash assistance, medical
assistance and food stamps unless the applicant expressly
declines in writing to apply for particular benefits. The

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Illinois Department shall adopt policies and procedures to
facilitate timely changes between programs that result from
changes in categorical eligibility factors.
The County departments, local governmental units and the
Illinois Department shall assist applicants for public
assistance to properly complete their applications. Such
assistance shall include, but not be limited to, assistance in
securing evidence in support of their eligibility.
(Source: P.A. 104-9, eff. 6-16-25.)
(305 ILCS 5/11-5.1)
Sec. 11-5.1. Eligibility verification. Notwithstanding any
other provision of this Code, with respect to applications for
medical assistance provided under Article V of this Code,
eligibility shall be determined in a manner that ensures
program integrity and complies with federal laws and
regulations while minimizing unnecessary barriers to
enrollment. To this end, as soon as practicable, and unless
the Department receives written denial from the federal
government, this Section shall be implemented:
(a) The Department of Healthcare and Family Services or
its designees shall:
(1) By no later than July 1, 2011, require
verification of, at a minimum, one month's income from all
sources required for determining the eligibility of
applicants for medical assistance under this Code. Such

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verification shall take the form of pay stubs, business or
income and expense records for self-employed persons,
letters from employers, and any other valid documentation
of income including data obtained electronically by the
Department or its designees from other sources as
described in subsection (b) of this Section. A month's
income may be verified by a single pay stub with the
monthly income extrapolated from the time period covered
by the pay stub.
(2) By no later than October 1, 2011, require
verification of, at a minimum, one month's income from all
sources required for determining the continued eligibility
of recipients at their annual review of eligibility for
medical assistance under this Code. Information the
Department receives prior to the annual review, including
information available to the Department as a result of the
recipient's application for other non-Medicaid benefits,
that is sufficient to make a determination of continued
Medicaid eligibility may be reviewed and verified, and
subsequent action taken including client notification of
continued Medicaid eligibility. The date of client
notification establishes the date for subsequent annual
Medicaid eligibility reviews. Such verification shall take
the form of pay stubs, business or income and expense
records for self-employed persons, letters from employers,
and any other valid documentation of income including data

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obtained electronically by the Department or its designees
from other sources as described in subsection (b) of this
Section. A month's income may be verified by a single pay
stub with the monthly income extrapolated from the time
period covered by the pay stub. The Department shall send
a notice to recipients at least 60 days prior to the end of
their period of eligibility that informs them of the
requirements for continued eligibility. If a recipient
does not fulfill the requirements for continued
eligibility by the deadline established in the notice a
notice of cancellation shall be issued to the recipient
and coverage shall end no later than the last day of the
month following the last day of the eligibility period. A
recipient's eligibility may be reinstated without
requiring a new application if the recipient fulfills the
requirements for continued eligibility prior to the end of
the third month following the last date of coverage (or
longer period if required by federal regulations). Nothing
in this Section shall prevent an individual whose coverage
has been cancelled from reapplying for health benefits at
any time.
(3) By no later than July 1, 2011, require
verification of Illinois residency.
The Department, with federal approval, may choose to adopt
continuous financial eligibility for a full 12 months for
adults on Medicaid.

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(b) The Department shall establish or continue cooperative
arrangements with the Social Security Administration, the
Illinois Secretary of State, the Department of Human Services,
the Department of Revenue, the Department of Employment
Security, and any other appropriate entity to gain electronic
access, to the extent allowed by law, to information available
to those entities that may be appropriate for electronically
verifying any factor of eligibility for benefits under the
Program. Data relevant to eligibility shall be provided for no
other purpose than to verify the eligibility of new applicants
or current recipients of health benefits under the Program.
Data shall be requested or provided for any new applicant or
current recipient only insofar as that individual's
circumstances are relevant to that individual's or another
individual's eligibility.
(c) Within 90 days of the effective date of this
amendatory Act of the 96th General Assembly, the Department of
Healthcare and Family Services shall send notice to current
recipients informing them of the changes regarding their
eligibility verification.
(d) As soon as practical if the data is reasonably
available, but no later than January 1, 2017, the Department
shall compile on a monthly basis data on eligibility
redeterminations of beneficiaries of medical assistance
provided under Article V of this Code. In addition to the other
data required under this subsection, the Department shall

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compile on a monthly basis data on the percentage of
beneficiaries whose eligibility is renewed through ex parte
redeterminations as described in subsection (b) of Section
5-1.6 of this Code, subject to federal approval of the changes
made in subsection (b) of Section 5-1.6 by this amendatory Act
of the 102nd General Assembly. This data shall be posted on the
Department's website, and data from prior months shall be
retained and available on the Department's website. The data
compiled and reported shall include the following:
(1) The total number of redetermination decisions made
in a month and, of that total number, the number of
decisions to continue or change benefits and the number of
decisions to cancel benefits.
(2) A breakdown of enrollee language preference for
the total number of redetermination decisions made in a
month and, of that total number, a breakdown of enrollee
language preference for the number of decisions to
continue or change benefits, and a breakdown of enrollee
language preference for the number of decisions to cancel
benefits. The language breakdown shall include, at a
minimum, English, Spanish, and the next 4 most commonly
used languages.
(3) The percentage of cancellation decisions made in a
month due to each of the following:
(A) The beneficiary's ineligibility due to excess
income.

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(B) The beneficiary's ineligibility due to not
being an Illinois resident.
(C) The beneficiary's ineligibility due to being
deceased.
(D) The beneficiary's request to cancel benefits.
(E) The beneficiary's lack of response after
notices mailed to the beneficiary are returned to the
Department as undeliverable by the United States
Postal Service.
(F) The beneficiary's lack of response to a
request for additional information when reliable
information in the beneficiary's account, or other
more current information, is unavailable to the
Department to make a decision on whether to continue
benefits.
(G) Other reasons tracked by the Department for
the purpose of ensuring program integrity.
(4) If a vendor is utilized to provide services in
support of the Department's redetermination decision
process, the total number of redetermination decisions
made in a month and, of that total number, the number of
decisions to continue or change benefits, and the number
of decisions to cancel benefits (i) with the involvement
of the vendor and (ii) without the involvement of the
vendor.
(5) Of the total number of benefit cancellations in a

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month, the number of beneficiaries who return from
cancellation within one month, the number of beneficiaries
who return from cancellation within 2 months, and the
number of beneficiaries who return from cancellation
within 3 months. Of the number of beneficiaries who return
from cancellation within 3 months, the percentage of those
cancellations due to each of the reasons listed under
paragraph (3) of this subsection.
(e) The Department shall conduct a complete review of the
Medicaid redetermination process in order to identify changes
that can increase the use of ex parte redetermination
processing. This review shall be completed within 90 days
after the effective date of this amendatory Act of the 101st
General Assembly. Within 90 days of completion of the review,
the Department shall seek written federal approval of policy
changes the review recommended and implement once approved.
The review shall specifically include, but not be limited to,
use of ex parte redeterminations of the following populations:
(1) Recipients of developmental disabilities services.
(2) Recipients of benefits under the State's Aid to
the Aged, Blind, or Disabled program.
(3) Recipients of Medicaid long-term care services and
supports, including waiver services.
(4) All Modified Adjusted Gross Income (MAGI)
populations.
(5) Populations with no verifiable income.

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(6) Self-employed people.
The report shall also outline populations and
circumstances in which an ex parte redetermination is not a
recommended option.
(f) The Department shall explore and implement, as
practical and technologically possible, roles that
stakeholders outside State agencies can play to assist in
expediting eligibility determinations and redeterminations
within 24 months after the effective date of this amendatory
Act of the 101st General Assembly. Such practical roles to be
explored to expedite the eligibility determination processes
shall include the implementation of hospital presumptive
eligibility, as authorized by the Patient Protection and
Affordable Care Act.
(g) The Department or its designee shall seek federal
approval to enhance the reasonable compatibility standard from
5% to 10%.
(h) Reporting. The Department of Healthcare and Family
Services and the Department of Human Services shall publish
quarterly reports on their progress in implementing policies
and practices pursuant to this Section as modified by this
amendatory Act of the 101st General Assembly.
(1) The reports shall include, but not be limited to,
the following:
(A) Medical application processing, including a
breakdown of the number of MAGI, non-MAGI, long-term

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care, and other medical cases pending for various
incremental time frames between 0 to 181 or more days.
(B) Medical redeterminations completed, including:
(i) a breakdown of the number of households that were
redetermined ex parte and those that were not; (ii)
the reasons households were not redetermined ex parte;
and (iii) the relative percentages of these reasons.
(C) A narrative discussion on issues identified in
the functioning of the State's Integrated Eligibility
System and progress on addressing those issues, as
well as progress on implementing strategies to address
eligibility backlogs, including expanding ex parte
determinations to ensure timely eligibility
determinations and renewals.
(2) Initial reports shall be issued within 90 days
after the effective date of this amendatory Act of the
101st General Assembly.
(3) All reports shall be published on the Department's
website.
(i) It is the determination of the General Assembly that
the Department must include seniors and persons with
disabilities in ex parte renewals. It is the determination of
the General Assembly that the Department must use its asset
verification system to assist in the determination of whether
an individual's coverage can be renewed using the ex parte
process. If a State Plan amendment is required, the Department

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shall pursue such State Plan amendment by July 1, 2022. Within
60 days after receiving federal approval or guidance, the
Department of Healthcare and Family Services and the
Department of Human Services shall make necessary technical
and rule changes to implement these changes to the
redetermination process.
(Source: P.A. 101-209, eff. 8-5-19; 101-649, eff. 7-7-20;
102-1037, eff. 6-2-22.)
(305 ILCS 5/11-5.4)
Sec. 11-5.4. Expedited long-term care eligibility
determination and enrollment.
(a) Establishment of the expedited long-term care
eligibility determination and enrollment system shall be a
joint venture of the Departments of Human Services and
Healthcare and Family Services and the Department on Aging.
(b) Streamlined application enrollment process; expedited
eligibility process. The streamlined application and
enrollment process must include, but need not be limited to,
the following:
(1) On or before July 1, 2019, a streamlined
application and enrollment process shall be put in place
which must include, but need not be limited to, the
following:
(A) Minimize the burden on applicants by
collecting only the data necessary to determine

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eligibility for medical services, long-term care
services, and spousal impoverishment offset.
(B) Integrate online data sources to simplify the
application process by reducing the amount of
information needed to be entered and to expedite
eligibility verification.
(C) Provide online prompts to alert the applicant
that information is missing or not complete.
(D) Provide training and step-by-step written
instructions for caseworkers, applicants, and
providers.
(2) The State must expedite the eligibility process
for applicants meeting specified guidelines, regardless of
the age of the application. The guidelines, subject to
federal approval, must include, but need not be limited
to, the following individually or collectively:
(A) Full Medicaid benefits in the community for a
specified period of time.
(B) No transfer of assets or resources during the
federally prescribed look-back period, as specified in
federal law.
(C) Receives Supplemental Security Income payments
or was receiving such payments at the time of
admission to a nursing facility.
(D) For applicants or recipients with verified
income at or below 100% of the federal poverty level

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when the declared value of their countable resources
is no greater than the allowable amounts pursuant to
Section 5-2 of this Code for classes of eligible
persons for whom a resource limit applies. Such
simplified verification policies shall apply to
community cases as well as long-term care cases.
(3) Subject to federal approval, the Department of
Healthcare and Family Services must implement an ex parte
renewal process for Medicaid-eligible individuals residing
in long-term care facilities. "Renewal" has the same
meaning as "redetermination" in State policies,
administrative rule, and federal Medicaid law. The ex
parte renewal process must be fully operational on or
before January 1, 2019. If an individual has transferred
to another long-term care facility, any annual notice
concerning redetermination of eligibility must be sent to
the long-term care facility where the individual resides
as well as to the individual.
(4) The Department of Human Services must use the
standards and distribution requirements described in this
subsection and in Section 11-6 for notification of missing
supporting documents and information during all phases of
the application process: initial, renewal, and appeal.
(c) The Department of Human Services must adopt policies
and procedures to improve communication between long-term care
benefits central office personnel, applicants and their

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representatives, and facilities in which the applicants
reside. Such policies and procedures must at a minimum permit
applicants and their representatives and the facility in which
the applicants reside to speak directly to an individual
trained to take telephone inquiries and provide appropriate
responses.
(d) Effective 30 days after the completion of 3 regionally
based trainings, nursing facilities shall submit all
applications for medical assistance online via the Application
for Benefits Eligibility (ABE) website. This requirement shall
extend to scanning and uploading with the online application
any required additional forms such as the Long Term Care
Facility Notification and the Additional Financial Information
for Long Term Care Applicants as well as scanned copies of any
supporting documentation. Long-term care facility admission
documents must be submitted as required in Section 5-5 of this
Code. No local Department of Human Services office shall
refuse to accept an electronically filed application. No
Department of Human Services office shall request submission
of any document in hard copy.
(e) Notwithstanding any other provision of this Code, the
Department of Human Services and the Department of Healthcare
and Family Services' Office of the Inspector General shall,
upon request, allow an applicant additional time to submit
information and documents needed as part of a review of
available resources or resources transferred during the

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look-back period. The initial extension shall not exceed 30
days. A second extension of 30 days may be granted upon
request. Any request for information issued by the State to an
applicant shall include the following: an explanation of the
information required and the date by which the information
must be submitted; a statement that failure to respond in a
timely manner can result in denial of the application; a
statement that the applicant or the facility in the name of the
applicant may seek an extension; and the name and contact
information of a caseworker in case of questions. Any such
request for information shall also be sent to the facility. In
deciding whether to grant an extension, the Department of
Human Services or the Department of Healthcare and Family
Services' Office of the Inspector General shall take into
account what is in the best interest of the applicant. The time
limits for processing an application shall be tolled during
the period of any extension granted under this subsection.
(f) The Department of Human Services and the Department of
Healthcare and Family Services must jointly compile data on
pending applications, denials, appeals, and redeterminations
into a monthly report, which shall be posted on each
Department's website for the purposes of monitoring long-term
care eligibility processing. The report must specify the
number of applications and redeterminations pending long-term
care eligibility determination and admission and the number of
appeals of denials in the following categories:

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(A) Length of time applications, redeterminations, and
appeals are pending - 0 to 45 days, 46 days to 90 days, 91
days to 180 days, 181 days to 12 months, over 12 months to
18 months, over 18 months to 24 months, and over 24 months.
(B) Percentage of applications and redeterminations
pending in the Department of Human Services' Family
Community Resource Centers, in the Department of Human
Services' long-term care hubs, with the Department of
Healthcare and Family Services' Office of Inspector
General, and those applications which are being tolled due
to requests for extension of time for additional
information.
(C) Status of pending applications, denials, appeals,
and redeterminations.
(g) Beginning on July 1, 2017, the Auditor General shall
report every 3 years to the General Assembly on the
performance and compliance of the Department of Healthcare and
Family Services, the Department of Human Services, and the
Department on Aging in meeting the requirements of this
Section and the federal requirements concerning eligibility
determinations for Medicaid long-term care services and
supports, and shall report any issues or deficiencies and make
recommendations. The Auditor General shall, at a minimum,
review, consider, and evaluate the following:
(1) compliance with federal regulations on furnishing
services as related to Medicaid long-term care services

10400SB3365ham001 - 360 - LRB104 18483 KTG 38682 a
and supports as provided under 42 CFR 435.930;
(2) compliance with federal regulations on the timely
determination of eligibility as provided under 42 CFR
435.912;
(3) the accuracy and completeness of the report
required under paragraph (9) of subsection (e);
(4) the efficacy and efficiency of the task-based
process used for making eligibility determinations in the
centralized offices of the Department of Human Services
for long-term care services, including the role of the
State's integrated eligibility system, as opposed to the
traditional caseworker-specific process from which these
central offices have converted; and
(5) any issues affecting eligibility determinations
related to the Department of Human Services' staff
completing Medicaid eligibility determinations instead of
the designated single-state Medicaid agency in Illinois,
the Department of Healthcare and Family Services.
The Auditor General's report shall include any and all
other areas or issues which are identified through an annual
review. Paragraphs (1) through (5) of this subsection shall
not be construed to limit the scope of the annual review and
the Auditor General's authority to thoroughly and completely
evaluate any and all processes, policies, and procedures
concerning compliance with federal and State law requirements
on eligibility determinations for Medicaid long-term care

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services and supports.
(h) The Department of Healthcare and Family Services shall
adopt any rules necessary to administer and enforce any
provision of this Section. Rulemaking shall not delay the full
implementation of this Section.
(i) Beginning on June 29, 2018, provisional eligibility
for medical assistance under Article V of this Code, in the
form of a recipient identification number and any other
necessary credentials to permit an applicant to receive
covered services under Article V, must be issued to any
applicant who has not received a determination on his or her
application for Medicaid and Medicaid long-term care services
filed simultaneously or, if already Medicaid enrolled,
application for Medicaid long-term care services under Article
V of this Code within the federally prescribed timeliness
requirements for determinations on such applications. The
Department of Healthcare and Family Services must maintain the
applicant's provisional eligibility status until a
determination is made on the individual's application for
long-term care services. The Department of Healthcare and
Family Services or the managed care organization, if
applicable, must reimburse providers for services rendered
during an applicant's provisional eligibility period.
(1) Claims for services rendered to an applicant with
provisional eligibility status must be submitted and
processed in the same manner as those submitted on behalf

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of beneficiaries determined to qualify for benefits.
(2) An applicant with provisional eligibility status
must have his or her long-term care benefits paid for
under the State's fee-for-service system during the period
of provisional eligibility. If an individual otherwise
eligible for medical assistance under Article V of this
Code is enrolled with a managed care organization for
community benefits at the time the individual's
provisional eligibility for long-term care services is
issued, the managed care organization is only responsible
for paying benefits covered under the capitation payment
received by the managed care organization for the
individual.
(3) The Department of Healthcare and Family Services,
within 10 business days of issuing provisional eligibility
to an applicant, must submit to the Office of the
Comptroller for payment a voucher for all retroactive
reimbursement due. The Department of Healthcare and Family
Services must clearly identify such vouchers as
provisional eligibility vouchers.
(Source: P.A. 101-101, eff. 1-1-20; 101-209, eff. 8-5-19;
101-265, eff. 8-9-19; 101-559, eff. 8-23-19; 102-558, eff.
8-20-21.)
ARTICLE 225.

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Section 225-5. The Illinois Act on the Aging is amended by
changing Section 4.02 as follows:
(20 ILCS 105/4.02)
Sec. 4.02. Community Care Program. The Department shall
establish a program of services to prevent unnecessary
institutionalization of persons age 60 and older in need of
long term care or who are established as persons who suffer
from Alzheimer's disease or a related disorder under the
Alzheimer's Disease Assistance Act, thereby enabling them to
remain in their own homes or in other living arrangements.
Such preventive services, which may be coordinated with other
programs for the aged, may include, but are not limited to, any
or all of the following:
(a) (blank);
(b) (blank);
(c) home care aide services;
(d) personal assistant services;
(e) adult day services;
(f) home-delivered meals;
(g) education in self-care;
(h) personal care services;
(i) adult day health services;
(j) habilitation services;
(k) respite care;
(k-5) community reintegration services;

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(k-6) flexible senior services;
(k-7) medication management;
(k-8) emergency home response;
(l) other nonmedical social services that may enable
the person to become self-supporting; or
(m) (blank).
The Department shall establish eligibility standards for
such services. In determining the amount and nature of
services for which a person may qualify, consideration shall
not be given to the value of cash, property, or other assets
held in the name of the person's spouse pursuant to a written
agreement dividing marital property into equal but separate
shares or pursuant to a transfer of the person's interest in a
home to his spouse, provided that the spouse's share of the
marital property is not made available to the person seeking
such services.
The Department shall require as a condition of eligibility
that all new financially eligible applicants apply for and
enroll in medical assistance under Article V of the Illinois
Public Aid Code in accordance with rules promulgated by the
Department.
The Department shall, in conjunction with the Department
of Public Aid (now Department of Healthcare and Family
Services), seek appropriate amendments under Sections 1915 and
1924 of the Social Security Act. The purpose of the amendments
shall be to extend eligibility for home and community based

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services under Sections 1915 and 1924 of the Social Security
Act to persons who transfer to or for the benefit of a spouse
those amounts of income and resources allowed under Section
1924 of the Social Security Act. Subject to the approval of
such amendments, the Department shall extend the provisions of
Section 5-4 of the Illinois Public Aid Code to persons who, but
for the provision of home or community-based services, would
require the level of care provided in an institution, as is
provided for in federal law. Those persons no longer found to
be eligible for receiving noninstitutional services due to
changes in the eligibility criteria shall be given 45 days
notice prior to actual termination. Those persons receiving
notice of termination may contact the Department and request
the determination be appealed at any time during the 45 day
notice period. The target population identified for the
purposes of this Section are persons age 60 and older with an
identified service need. Priority shall be given to those who
are at imminent risk of institutionalization. The services
shall be provided to eligible persons age 60 and older to the
extent that the cost of the services together with the other
personal maintenance expenses of the persons are reasonably
related to the standards established for care in a group
facility appropriate to the person's condition. These
noninstitutional services, pilot projects, or experimental
facilities may be provided as part of or in addition to those
authorized by federal law or those funded and administered by

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the Department of Human Services. The Departments of Human
Services, Healthcare and Family Services, Public Health,
Veterans' Affairs, and Commerce and Economic Opportunity and
other appropriate agencies of State, federal, and local
governments shall cooperate with the Department on Aging in
the establishment and development of the noninstitutional
services. The Department shall require an annual audit from
all personal assistant and home care aide vendors contracting
with the Department under this Section. The annual audit shall
assure that each audited vendor's procedures are in compliance
with Department's financial reporting guidelines requiring an
administrative and employee wage and benefits cost split as
defined in administrative rules. The audit is a public record
under the Freedom of Information Act. The Department shall
execute, relative to the nursing home prescreening project,
written inter-agency agreements with the Department of Human
Services and the Department of Healthcare and Family Services,
to effect the following: (1) intake procedures and common
eligibility criteria for those persons who are receiving
noninstitutional services; and (2) the establishment and
development of noninstitutional services in areas of the State
where they are not currently available or are undeveloped. On
and after July 1, 1996, all nursing home prescreenings for
individuals 60 years of age or older shall be conducted by the
Department.
As part of the Department on Aging's routine training of

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case managers and case manager supervisors, the Department may
include information on family futures planning for persons who
are age 60 or older and who are caregivers of their adult
children with developmental disabilities. The content of the
training shall be at the Department's discretion.
The Department is authorized to establish a system of
recipient copayment for services provided under this Section,
such copayment to be based upon the recipient's ability to pay
but in no case to exceed the actual cost of the services
provided. Additionally, any portion of a person's income which
is equal to or less than the federal poverty standard shall not
be considered by the Department in determining the copayment.
The level of such copayment shall be adjusted whenever
necessary to reflect any change in the officially designated
federal poverty standard.
The Department, or the Department's authorized
representative, may recover the amount of moneys expended for
services provided to or in behalf of a person under this
Section by a claim against the person's estate or against the
estate of the person's surviving spouse, but no recovery may
be had until after the death of the surviving spouse, if any,
and then only at such time when there is no surviving child who
is under age 21 or blind or who has a permanent and total
disability. This paragraph, however, shall not bar recovery,
at the death of the person, of moneys for services provided to
the person or in behalf of the person under this Section to

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which the person was not entitled; provided that such recovery
shall not be enforced against any real estate while it is
occupied as a homestead by the surviving spouse or other
dependent, if no claims by other creditors have been filed
against the estate, or, if such claims have been filed, they
remain dormant for failure of prosecution or failure of the
claimant to compel administration of the estate for the
purpose of payment. This paragraph shall not bar recovery from
the estate of a spouse, under Sections 1915 and 1924 of the
Social Security Act and Section 5-4 of the Illinois Public Aid
Code, who precedes a person receiving services under this
Section in death. All moneys for services paid to or in behalf
of the person under this Section shall be claimed for recovery
from the deceased spouse's estate. "Homestead", as used in
this paragraph, means the dwelling house and contiguous real
estate occupied by a surviving spouse or relative, as defined
by the rules and regulations of the Department of Healthcare
and Family Services, regardless of the value of the property.
The Department shall increase the effectiveness of the
existing Community Care Program by:
(1) ensuring that in-home services included in the
care plan are available on evenings and weekends;
(2) ensuring that care plans contain the services that
eligible participants need based on the number of days in
a month, not limited to specific blocks of time, as
identified by the comprehensive assessment tool selected

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by the Department for use statewide, not to exceed the
total monthly service cost maximum allowed for each
service; the Department shall develop administrative rules
to implement this item (2);
(3) ensuring that the participants have the right to
choose the services contained in their care plan and to
direct how those services are provided, based on
administrative rules established by the Department;
(4)(blank);
(5) ensuring that homemakers can provide personal care
services that may or may not involve contact with clients,
including, but not limited to:
(A) bathing;
(B) grooming;
(C) toileting;
(D) nail care;
(E) transferring;
(F) respiratory services;
(G) exercise; or
(H) positioning;
(6) ensuring that homemaker program vendors are not
restricted from hiring homemakers who are family members
of clients or recommended by clients; the Department may
not, by rule or policy, require homemakers who are family
members of clients or recommended by clients to accept
assignments in homes other than the client;

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(7) ensuring that the State may access maximum federal
matching funds by seeking approval for the Centers for
Medicare and Medicaid Services for modifications to the
State's home and community based services waiver and
additional waiver opportunities, including applying for
enrollment in the Balance Incentive Payment Program by May
1, 2013, in order to maximize federal matching funds; this
shall include, but not be limited to, modification that
reflects all changes in the Community Care Program
services and all increases in the services cost maximum;
(8) ensuring that the determination of need tool
accurately reflects the service needs of individuals with
Alzheimer's disease and related dementia disorders;
(9) ensuring that services are authorized accurately
and consistently for the Community Care Program (CCP); the
Department shall implement a Service Authorization policy
directive; the purpose shall be to ensure that eligibility
and services are authorized accurately and consistently in
the CCP program; the policy directive shall clarify
service authorization guidelines to Care Coordination
Units and Community Care Program providers no later than
May 1, 2013;
(10) working in conjunction with Care Coordination
Units, the Department of Healthcare and Family Services,
the Department of Human Services, Community Care Program
providers, and other stakeholders to make improvements to

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the Medicaid claiming processes and the Medicaid
enrollment procedures or requirements as needed,
including, but not limited to, specific policy changes or
rules to improve the up-front enrollment of participants
in the Medicaid program and specific policy changes or
rules to ensure insure more prompt submission of bills to
the federal government to secure maximum federal matching
dollars as promptly as possible; the Department on Aging
shall have at least 3 meetings with stakeholders by
January 1, 2014 in order to address these improvements;
(11) requiring home care service providers to comply
with the rounding of hours worked provisions under the
federal Fair Labor Standards Act (FLSA) and as set forth
in 29 CFR 785.48(b) by May 1, 2013;
(12) implementing any necessary policy changes or
promulgating any rules, no later than January 1, 2014, to
assist the Department of Healthcare and Family Services in
moving as many participants as possible, consistent with
federal regulations, into coordinated care plans if a care
coordination plan that covers long term care is available
in the recipient's area; and
(13) (blank).
By January 1, 2009 or as soon after the end of the Cash and
Counseling Demonstration Project as is practicable, the
Department may, based on its evaluation of the demonstration
project, promulgate rules concerning personal assistant

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services, to include, but need not be limited to,
qualifications, employment screening, rights under fair labor
standards, training, fiduciary agent, and supervision
requirements. All applicants shall be subject to the
provisions of the Health Care Worker Background Check Act.
The Department shall develop procedures to enhance
availability of services on evenings, weekends, and on an
emergency basis to meet the respite needs of caregivers.
Procedures shall be developed to permit the utilization of
services in successive blocks of 24 hours up to the monthly
maximum established by the Department. Workers providing these
services shall be appropriately trained.
No person may perform chore/housekeeping and home care
aide services under a program authorized by this Section
unless that person has been issued a certificate of
pre-service to do so by his or her employing agency.
Information gathered to effect such certification shall
include (i) the person's name, (ii) the date the person was
hired by his or her current employer, and (iii) the training,
including dates and levels. Persons engaged in the program
authorized by this Section before the effective date of this
amendatory Act of 1991 shall be issued a certificate of all
pre-service and in-service training from his or her employer
upon submitting the necessary information. The employing
agency shall be required to retain records of all staff
pre-service and in-service training, and shall provide such

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records to the Department upon request and upon termination of
the employer's contract with the Department. In addition, the
employing agency is responsible for the issuance of
certifications of in-service training completed to their
employees.
The Department is required to develop a system to ensure
that persons working as home care aides and personal
assistants receive increases in their wages when the federal
minimum wage is increased by requiring vendors to certify that
they are meeting the federal minimum wage statute for home
care aides and personal assistants. An employer that cannot
ensure that the minimum wage increase is being given to home
care aides and personal assistants shall be denied any
increase in reimbursement costs.
The Community Care Program Advisory Committee is created
in the Department on Aging. The Director shall appoint
individuals to serve in the Committee, who shall serve at
their own expense. Members of the Committee must abide by all
applicable ethics laws. The Committee shall advise the
Department on issues related to the Department's program of
services to prevent unnecessary institutionalization. The
Committee shall meet on a bi-monthly basis and shall serve to
identify and advise the Department on present and potential
issues affecting the service delivery network, the program's
clients, and the Department and to recommend solution
strategies. Persons appointed to the Committee shall be

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appointed on, but not limited to, their own and their agency's
experience with the program, geographic representation, and
willingness to serve. The Director shall appoint members to
the Committee to represent provider, advocacy, policy
research, and other constituencies committed to the delivery
of high quality home and community-based services to older
adults. Representatives shall be appointed to ensure
representation from community care providers, including, but
not limited to, adult day service providers, homemaker
providers, case coordination and case management units,
emergency home response providers, statewide trade or labor
unions that represent home care aides and direct care staff,
area agencies on aging, adults over age 60, membership
organizations representing older adults, and other
organizational entities, providers of care, or individuals
with demonstrated interest and expertise in the field of home
and community care as determined by the Director.
Nominations may be presented from any agency or State
association with interest in the program. The Director, or his
or her designee, shall serve as the permanent co-chair of the
advisory committee. One other co-chair shall be nominated and
approved by the members of the committee on an annual basis.
Committee members' terms of appointment shall be for 4 years
with one-quarter of the appointees' terms expiring each year.
A member shall continue to serve until his or her replacement
is named. The Department shall fill vacancies that have a

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remaining term of over one year, and this replacement shall
occur through the annual replacement of expiring terms. The
Director shall designate Department staff to provide technical
assistance and staff support to the committee. Department
representation shall not constitute membership of the
committee. All Committee papers, issues, recommendations,
reports, and meeting memoranda are advisory only. The
Director, or his or her designee, shall make a written report,
as requested by the Committee, regarding issues before the
Committee.
The Department on Aging and the Department of Human
Services shall cooperate in the development and submission of
an annual report on programs and services provided under this
Section. Such joint report shall be filed with the Governor
and the General Assembly on or before March 31 of the following
fiscal year.
The requirement for reporting to the General Assembly
shall be satisfied by filing copies of the report as required
by Section 3.1 of the General Assembly Organization Act and
filing such additional copies with the State Government Report
Distribution Center for the General Assembly as is required
under paragraph (t) of Section 7 of the State Library Act.
Those persons previously found eligible for receiving
noninstitutional services whose services were discontinued
under the Emergency Budget Act of Fiscal Year 1992, and who do
not meet the eligibility standards in effect on or after July

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1, 1992, shall remain ineligible on and after July 1, 1992.
Those persons previously not required to cost-share and who
were required to cost-share effective March 1, 1992, shall
continue to meet cost-share requirements on and after July 1,
1992. Beginning July 1, 1992, all clients will be required to
meet eligibility, cost-share, and other requirements and will
have services discontinued or altered when they fail to meet
these requirements.
For the purposes of this Section, "flexible senior
services" refers to services that require one-time or periodic
expenditures, including, but not limited to, respite care,
home modification, assistive technology, housing assistance,
and transportation.
The Department shall implement an electronic service
verification based on global positioning systems or other
cost-effective technology for the Community Care Program no
later than January 1, 2014.
The Department shall require, as a condition of
eligibility, application for the medical assistance program
under Article V of the Illinois Public Aid Code.
The Department may authorize Community Care Program
services until an applicant is determined eligible for medical
assistance under Article V of the Illinois Public Aid Code.
The Department shall continue to provide Community Care
Program reports as required by statute, which shall include an
annual report on Care Coordination Unit performance and

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adherence to service guidelines and a 6-month supplemental
report.
In regard to community care providers, failure to comply
with Department on Aging policies shall be cause for
disciplinary action, including, but not limited to,
disqualification from serving Community Care Program clients.
Each provider, upon submission of any bill or invoice to the
Department for payment for services rendered, shall include a
notarized statement, under penalty of perjury pursuant to
Section 1-109 of the Code of Civil Procedure, that the
provider has complied with all Department policies.
The Director of the Department on Aging shall make
information available to the State Board of Elections as may
be required by an agreement the State Board of Elections has
entered into with a multi-state voter registration list
maintenance system.
The Department shall pay an enhanced rate of at least
$1.77 per unit under the Community Care Program to those
in-home service provider agencies that offer health insurance
coverage as a benefit to their direct service worker employees
pursuant to rules adopted by the Department. The Department
shall review the enhanced rate as part of its process to rebase
in-home service provider reimbursement rates pursuant to
federal waiver requirements. Subject to federal approval,
beginning on January 1, 2024, rates for adult day services
shall be increased to $16.84 per hour and rates for each way

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transportation services for adult day services shall be
increased to $12.44 per unit transportation.
Subject to federal approval, on and after January 1, 2024,
rates for homemaker services shall be increased to $28.07 to
sustain a minimum wage of $17 per hour for direct service
workers. Rates in subsequent State fiscal years shall be no
lower than the rates put into effect upon federal approval.
Providers of in-home services shall be required to certify to
the Department that they remain in compliance with the
mandated wage increase for direct service workers. Fringe
benefits, including, but not limited to, paid time off and
payment for training, health insurance, travel, or
transportation, shall not be reduced in relation to the rate
increases described in this paragraph.
Subject to and upon federal approval, on and after January
1, 2025, rates for homemaker services shall be increased to
$29.63 to sustain a minimum wage of $18 per hour for direct
service workers. Rates in subsequent State fiscal years shall
be no lower than the rates put into effect upon federal
approval. Providers of in-home services shall be required to
certify to the Department that they remain in compliance with
the mandated wage increase for direct service workers. Fringe
benefits, including, but not limited to, paid time off and
payment for training, health insurance, travel, or
transportation, shall not be reduced in relation to the rate
increases described in this paragraph.

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Subject to and upon federal approval, on and after January
1, 2026, rates for homemaker services shall be increased to
$30.80 to sustain a minimum wage of $18.75 per hour for direct
service workers. Rates in subsequent State fiscal years shall
be no lower than the rates put into effect upon federal
approval. Providers of in-home services shall be required to
certify to the Department that they remain in compliance with
the mandated wage increase for direct service workers. Fringe
benefits, including, but not limited to, paid time off and
payment for training, health insurance, travel, or
transportation, shall not be reduced in relation to the rate
increases described in this paragraph.
The General Assembly finds it necessary to authorize an
aggressive Medicaid enrollment initiative designed to maximize
federal Medicaid funding for the Community Care Program which
produces significant savings for the State of Illinois. The
Department on Aging shall establish and implement a Community
Care Program Medicaid Initiative. Under the Initiative, the
Department on Aging shall, at a minimum: (i) provide an
enhanced rate to adequately compensate care coordination units
to enroll eligible Community Care Program clients into
Medicaid; (ii) use recommendations from a stakeholder
committee on how best to implement the Initiative; and (iii)
establish requirements for State agencies to make enrollment
in the State's Medical Assistance program easier for seniors.
The Community Care Program Medicaid Enrollment Oversight

10400SB3365ham001 - 380 - LRB104 18483 KTG 38682 a
Subcommittee is created as a subcommittee of the Older Adult
Services Advisory Committee established in Section 35 of the
Older Adult Services Act to make recommendations on how best
to increase the number of medical assistance recipients who
are enrolled in the Community Care Program. The Subcommittee
shall consist of all of the following persons who must be
appointed within 30 days after June 4, 2018 (the effective
date of Public Act 100-587):
(1) The Director of Aging, or his or her designee, who
shall serve as the chairperson of the Subcommittee.
(2) One representative of the Department of Healthcare
and Family Services, appointed by the Director of
Healthcare and Family Services.
(3) One representative of the Department of Human
Services, appointed by the Secretary of Human Services.
(4) One individual representing a care coordination
unit, appointed by the Director of Aging.
(5) One individual from a non-governmental statewide
organization that advocates for seniors, appointed by the
Director of Aging.
(6) One individual representing Area Agencies on
Aging, appointed by the Director of Aging.
(7) One individual from a statewide association
dedicated to Alzheimer's care, support, and research,
appointed by the Director of Aging.
(8) One individual from an organization that employs

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persons who provide services under the Community Care
Program, appointed by the Director of Aging.
(9) One member of a trade or labor union representing
persons who provide services under the Community Care
Program, appointed by the Director of Aging.
(10) One member of the Senate, who shall serve as
co-chairperson, appointed by the President of the Senate.
(11) One member of the Senate, who shall serve as
co-chairperson, appointed by the Minority Leader of the
Senate.
(12) One member of the House of Representatives, who
shall serve as co-chairperson, appointed by the Speaker of
the House of Representatives.
(13) One member of the House of Representatives, who
shall serve as co-chairperson, appointed by the Minority
Leader of the House of Representatives.
(14) One individual appointed by a labor organization
representing frontline employees at the Department of
Human Services.
The Subcommittee shall provide oversight to the Community
Care Program Medicaid Initiative and shall meet quarterly. At
each Subcommittee meeting the Department on Aging shall
provide the following data sets to the Subcommittee: (A) the
number of Illinois residents, categorized by planning and
service area, who are receiving services under the Community
Care Program and are enrolled in the State's Medical

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Assistance Program; (B) the number of Illinois residents,
categorized by planning and service area, who are receiving
services under the Community Care Program, but are not
enrolled in the State's Medical Assistance Program; and (C)
the number of Illinois residents, categorized by planning and
service area, who are receiving services under the Community
Care Program and are eligible for benefits under the State's
Medical Assistance Program, but are not enrolled in the
State's Medical Assistance Program. In addition to this data,
the Department on Aging shall provide the Subcommittee with
plans on how the Department on Aging will reduce the number of
Illinois residents who are not enrolled in the State's Medical
Assistance Program but who are eligible for medical assistance
benefits. The Department on Aging shall enroll in the State's
Medical Assistance Program those Illinois residents who
receive services under the Community Care Program and are
eligible for medical assistance benefits but are not enrolled
in the State's Medicaid Assistance Program. The data provided
to the Subcommittee shall be made available to the public via
the Department on Aging's website.
The Department on Aging, with the involvement of the
Subcommittee, shall collaborate with the Department of Human
Services and the Department of Healthcare and Family Services
on how best to achieve the responsibilities of the Community
Care Program Medicaid Initiative.
The Department on Aging, the Department of Human Services,

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and the Department of Healthcare and Family Services shall
coordinate and implement a streamlined process for seniors to
access benefits under the State's Medical Assistance Program.
The Subcommittee shall collaborate with the Department of
Human Services on the adoption of a uniform application
submission process. The Department of Human Services and any
other State agency involved with processing the medical
assistance application of any person enrolled in the Community
Care Program shall include the appropriate care coordination
unit in all communications related to the determination or
status of the application.
The Community Care Program Medicaid Initiative shall
provide targeted funding to care coordination units to help
seniors complete their applications for medical assistance
benefits. On and after July 1, 2019, care coordination units
shall receive no less than $200 per completed application,
which rate may be included in a bundled rate for initial intake
services when Medicaid application assistance is provided in
conjunction with the initial intake process for new program
participants.
The Community Care Program Medicaid Initiative shall cease
operation 5 years after June 4, 2018 (the effective date of
Public Act 100-587), after which the Subcommittee shall
dissolve.
Effective July 1, 2023 through June 30, 2026, subject to
federal approval, the Department on Aging shall reimburse Care

10400SB3365ham001 - 384 - LRB104 18483 KTG 38682 a
Coordination Units at the following rates for case management
services: $252.40 for each initial assessment; $366.40 for
each initial assessment with translation; $229.68 for each
redetermination assessment; $313.68 for each redetermination
assessment with translation; $200.00 for each completed
application for medical assistance benefits; $132.26 for each
face-to-face, choices-for-care screening; $168.26 for each
face-to-face, choices-for-care screening with translation;
$124.56 for each 6-month, face-to-face visit; $132.00 for each
MCO participant eligibility determination; and $157.00 for
each MCO participant eligibility determination with
translation.
Effective July 1, 2026, subject to federal approval, the
Department on Aging shall reimburse Care Coordination Units at
the following rates for case management services: $252.40 for
each initial assessment; $366.40 for each initial assessment
with translation; $229.68 for each redetermination assessment;
$313.68 for each redetermination assessment with translation;
$200.00 for each completed application for medical assistance
benefits; $132.26 for each face-to-face, choices-for-care
screening; $168.26 for each face-to-face, choices-for-care
screening with translation; $124.56 for each 6-month,
face-to-face visit; $172 for each managed care participant
eligibility determination; $197.00 for each managed care
participant eligibility determination with translation; and
$90 for each administration of a participant transfer from

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non-managed care CCP to managed care CCP or from managed care
CCP to non-managed care CCP.
(Source: P.A. 103-8, eff. 6-7-23; 103-102, Article 45, Section
45-5, eff. 1-1-24; 103-102, Article 85, Section 85-5, eff.
1-1-24; 103-102, Article 90, Section 90-5, eff. 1-1-24;
103-588, eff. 6-5-24; 103-605, eff. 7-1-24; 103-670, eff.
1-1-25; 104-2, eff. 6-16-25; 104-417, eff. 8-15-25.)
ARTICLE 230.
Section 230-5. The Specialized Mental Health
Rehabilitation Act of 2013 is amended by changing Sections
5-107 and 5-113 and by adding Section 5-114 as follows:
(210 ILCS 49/5-107)
Sec. 5-107. Quality of life enhancement. Beginning on July
1, 2019, for improving the quality of life and the quality of
care, an additional payment shall be awarded to a facility for
their single occupancy rooms. This payment shall be in
addition to the rate for recovery and rehabilitation. The
additional rate for single room occupancy shall be no less
than $10 per day, per single room occupancy. The Department of
Healthcare and Family Services shall adjust payment to
Medicaid managed care entities to cover these costs. Beginning
July 1, 2022, for improving the quality of life and the quality
of care, a payment of no less than $5 per day, per single room

10400SB3365ham001 - 386 - LRB104 18483 KTG 38682 a
occupancy shall be added to the existing $10 additional per
day, per single room occupancy rate for a total of at least $15
per day, per single room occupancy. For improving the quality
of life and the quality of care, on January 1, 2024, a payment
of no less than $10.50 per day, per single room occupancy shall
be added to the existing $15 additional per day, per single
room occupancy rate for a total of at least $25.50 per day, per
single room occupancy. For improving the quality of life and
the quality of care, beginning on January 1, 2025, a payment of
no less than $10 per day, per single room occupancy shall be
added to the existing $25.50 additional per day, per single
room occupancy rate for a total of at least $35.50 per day, per
single room occupancy. For improving the quality of life and
the quality of care, beginning on July 1, 2026, a payment of no
less than $8 per day, per single room occupancy shall be added
to the existing $35.50 additional per day, per single room
occupancy rate for a total of at least $43.50 per day, per
single room occupancy. Beginning July 1, 2022, for improving
the quality of life and the quality of care, an additional
payment shall be awarded to a facility for its dual-occupancy
rooms. This payment shall be in addition to the rate for
recovery and rehabilitation. The additional rate for
dual-occupancy rooms shall be no less than $10 per day, per
Medicaid-occupied bed, in each dual-occupancy room. Beginning
January 1, 2024, for improving the quality of life and the
quality of care, a payment of no less than $4.50 per day, per

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dual-occupancy room shall be added to the existing $10
additional per day, per dual-occupancy room rate for a total
of at least $14.50, per Medicaid-occupied bed, in each
dual-occupancy room. Beginning January 1, 2025, for improving
the quality of life and the quality of care, a payment of no
less than $8.75 per day, per dual-occupancy room shall be
added to the existing $14.50 additional per day, per
dual-occupancy room rate for a total of at least $23.25, per
Medicaid-occupied bed, in each dual-occupancy room. The
Department of Healthcare and Family Services shall adjust
payment to Medicaid managed care entities to cover these
costs. Beginning July 1, 2026, for improving the quality of
life and the quality of care, a payment of no less than $2.50
per day, per dual-occupancy room shall be added to the
existing $23.25 additional per day, per dual-occupancy room
rate for a total of at least $25.75, per Medicaid-occupied
bed, in each dual-occupancy room. The Department of Healthcare
and Family Services shall adjust payment to Medicaid managed
care entities to cover these costs. As used in this Section,
"dual-occupancy room" means a room that contains 2 resident
beds.
(Source: P.A. 102-699, eff. 4-19-22; 103-102, eff. 1-1-24;
103-593, eff. 6-7-24.)
(210 ILCS 49/5-113)
Sec. 5-113. Specialized mental health rehabilitation

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facility; one payment. Notwithstanding any other provision of
this Act to the contrary, beginning January 1, 2025, there
shall be a separate per diem add-on paid solely and
exclusively to facilities licensed under this Act that are
licensed for only single occupancy rooms and have reduced
their licensed capacity. No facility licensed under this Act
shall be eligible for these payments if the facility contains
any rooms that house more than a single occupant and has have
failed to reduce the facility's facilities' licensed capacity.
The payment shall be a per diem add-on payment. For
facilities with less than 100 licensed beds, the add-on
payment shall result in a rate not less than $240 per day. For
facilities with 100 licensed beds to 130 licensed beds, the
add-on payment shall result in a rate not less than $230 per
day. For facilities with more than 130 licensed beds, the
add-on payment shall result in a rate of not less than $220 per
day. All add-on rates shall be based upon the new licensed
capacity.
Any additional payments in effect after January 1, 2025
under Section 5-107 shall be paid in addition to the amounts
listed in this Section. Facilities receiving payments under
this Section shall receive payment as prescribed under Section
5-101.
Beginning July 1, 2026, for facilities with less than 100
licensed beds, the payment shall result in a rate not less than
$247.50 per day. Beginning July 1, 2026, for facilities with

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100 licensed beds to 130 licensed beds, the payment shall
result in a rate not less than $237.50 per day. For facilities
with more than 130 beds, the payment shall result in a rate of
no less than $225 per day.
(Source: P.A. 103-593, eff. 6-7-24.)
(210 ILCS 49/5-114 new)
Sec. 5-114. Forensic add-on payment. Notwithstanding any
other provisions to the contrary, any facility that provides
services to a resident found not guilty by reason of insanity
and is thereby deemed unable to stand trial shall receive an
additional payment of $15 per bed, per day for any resident
found not guilty by reason of insanity and is thereby deemed
unable to stand trial.
ARTICLE 235.
Section 235-5. The Department of Human Services Act is
amended by adding Section 10-13 as follows:
(20 ILCS 1305/10-13 new)
Sec. 10-13. Pilot programs with local government entities,
nonprofits, or privately funded programs. The Department of
Human Services may, subject to appropriation, establish pilot
programs with local government entities, nonprofits, or
privately funded programs seeking to provide financial or

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other support to residents of Illinois through current or
future benefit distribution methods utilized by the Department
of Human Services.
ARTICLE 240.
Section 240-5. The Illinois Public Aid Code is amended by
adding Section 5-54 as follows:
(305 ILCS 5/5-54 new)
Sec. 5-54. Coverage for proteomic blood tests.
(a) The medical assistance program shall provide coverage
and reimbursement for a prescribed proteomic blood test, with
clinical trial proof of improved infant outcomes published in
peer-reviewed journals, that identifies and quantifies the
risk of preterm birth for an individual pregnancy.
(b) The medical assistance program shall provide coverage
and reimbursement for remote patient management services,
including telecare management and remote physiologic
monitoring, that address maternity and postpartum care access
challenges for individualized care delivery by licensed
providers. Only remote patient management services with
evidence of improved patient care shall be covered and
reimbursed under this subsection.
ARTICLE 245.

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Section 245-5. The Illinois Public Aid Code is amended by
adding Section 5-30.19 as follows:
(305 ILCS 5/5-30.19 new)
Sec. 5-30.19. MCO behavioral health post-payment reviews.
(a) In this Section:
"Extrapolated" shall be used as "extrapolation" is used in
89 Ill. Adm. Code 140.30(b) or any successor rule.
"Managed care organization" or "MCO" has the meaning given
to that term in Section 5-30.1 of this Code.
"Post-payment review" means an examination that occurs
after payment is made by an MCO for a selected claim to
determine whether the initial determination for payment was
appropriate.
"Provider" means a community mental health center,
behavioral health clinic, certified community behavioral
health clinic, or substance use treatment and recovery center
that is enrolled in the medical assistance program and
contracted with or reimbursed by an MCO.
(b) Beginning July 1, 2027, when conducting post-payment
reviews of providers, MCOs must establish guidelines that
follow the Department's guidance. The Department's guidance
shall mandate that MCOs:
(1) Clearly define the documentation and the response
time frames ensuring that all requests are directly tied

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to the review objectives. Documentation and response time
frames do not apply to methods necessary for fraud, waste,
and abuse post-payment reviews, including, but not limited
to, unscheduled or unannounced site visits and database
checks.
(2) Identify regulatory, statutory, or contractual
authority and standards for conducting the post-payment
review.
(3) Clearly define evaluation criteria and provide
documentation checklists.
(4) Establish a process to dispute MCO record requests
not made in conformance with this Section.
(5) Establish a process and clarify the instances that
allow for entry and exit communications with providers to
clearly convey the review scope, expectations, preliminary
findings, compliance status, and next steps, ensuring
consistent messaging throughout the review process.
(6) Establish qualifications of reviewers with
relevant knowledge, experience, and training.
(7) Provide the data on how the provider varies
significantly from other providers in the same provider
type, service specialty, jurisdiction, or locality, if the
basis for selection of a provider for review is
comparative data except where fraud, waste, and abuse
processes and procedures prevent disclosure.
(8) Clearly outline communication protocols, including

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advance written notice, delivered electronically, by MCOs
to providers of documentation requests with an allowance
for reasonable response times and except for instances
where fraud, waste, and abuse processes and procedures
prevent advance notice, including, but not limited to,
unscheduled or unannounced site visits.
(9) Upon completion of the review, issue a formal
written notice of compliance or closure to the provider.
The final review findings shall include clear references
to applicable regulatory or contractual citations, an
explanation of the rationale for each finding, guidance on
required next steps or corrective actions, and information
regarding the process and timelines for appealing the
findings.
(10) Use the least burdensome and lowest-cost method
of record submission, including secure electronic methods,
when available. The date on which documentation is
received in the electronic communication shall be the
official date of receipt. All communication protocols
shall be compliant with privacy and security laws.
(11) Issue findings and related written communications
in a clear, consistent, and non-contradictory manner to
prevent confusion or conflicting conclusions.
(12) Disclose the methodology supporting any
extrapolated finding.
(c) The MCO shall post the guidelines and any updates on

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its publicly available website.
(d) Providers must not be subject to any adverse action,
payment delay, sanctions, or contract termination solely for
exercising the right to dispute a records request in
accordance with this Section, except for matters involving
allegations of fraud, waste, or abuse.
(e) Nothing in this Section shall be construed to conflict
with State or federal program integrity law, regulations,
guidance, processes, or procedures.
ARTICLE 250.
Section 250-5. The Illinois Public Aid Code is amended by
adding Section 5-70 as follows:
(305 ILCS 5/5-70 new)
Sec. 5-70. Virtual intensive outpatient program services.
For dates of service on and after January 1, 2027, subject to
any necessary federal approval, the medical assistance program
shall provide coverage for virtual intensive outpatient
program services when clinically appropriate, delivered in
line with generally accepted standards of care, and only at
the request of or with the consent of the patient. The
Department shall establish provider qualifications for
intensive outpatient program services offering a virtual
service delivery option. The Department may establish

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utilization controls and any appropriate guidelines for
coverage of the virtual intensive outpatient program to
protect the well-being of persons eligible and enrolled in the
medical assistance program. The Department may adopt rules
necessary to implement this Section.
ARTICLE 255.
Section 255-5. The Illinois Public Aid Code is amended by
changing Section 5-5.01a as follows:
(305 ILCS 5/5-5.01a)
Sec. 5-5.01a. Supportive living facilities program.
(a) The Department shall establish and provide oversight
for a program of supportive living facilities that seek to
promote resident independence, dignity, respect, and
well-being in the most cost-effective manner.
A supportive living facility is (i) a free-standing
facility or (ii) a distinct physical and operational entity
within a mixed-use building that meets the criteria
established in subsection (d). A supportive living facility
integrates housing with health, personal care, and supportive
services and is a designated setting that offers residents
their own separate, private, and distinct living units.
Sites for the operation of the program shall be selected
by the Department based upon criteria that may include the

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need for services in a geographic area, the availability of
funding, and the site's ability to meet the standards.
(b) Beginning July 1, 2014, subject to federal approval,
the Medicaid rates for supportive living facilities shall be
equal to the supportive living facility Medicaid rate
effective on June 30, 2014 increased by 8.85%. Once the
assessment imposed at Article V-G of this Code is determined
to be a permissible tax under Title XIX of the Social Security
Act, the Department shall increase the Medicaid rates for
supportive living facilities effective on July 1, 2014 by
9.09%. The Department shall apply this increase retroactively
to coincide with the imposition of the assessment in Article
V-G of this Code in accordance with the approval for federal
financial participation by the Centers for Medicare and
Medicaid Services.
The Medicaid rates for supportive living facilities
effective on July 1, 2017 must be equal to the rates in effect
for supportive living facilities on June 30, 2017 increased by
2.8%.
The Medicaid rates for supportive living facilities
effective on July 1, 2018 must be equal to the rates in effect
for supportive living facilities on June 30, 2018.
Subject to federal approval, the Medicaid rates for
supportive living services on and after July 1, 2019 must be at
least 54.3% of the average total nursing facility services per
diem for the geographic areas defined by the Department while

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maintaining the rate differential for dementia care and must
be updated whenever the total nursing facility service per
diems are updated. Beginning July 1, 2022, upon the
implementation of the Patient Driven Payment Model, Medicaid
rates for supportive living services must be at least 54.3% of
the average total nursing services per diem rate for the
geographic areas. For purposes of this provision, the average
total nursing services per diem rate shall include all add-ons
for nursing facilities for the geographic area provided for in
Section 5-5.2. The rate differential for dementia care must be
maintained in these rates and the rates shall be updated
whenever nursing facility per diem rates are updated.
Subject to federal approval, beginning January 1, 2024,
the dementia care rate for supportive living services must be
no less than the non-dementia care supportive living services
rate multiplied by 1.5.
(b-5) Subject to federal approval, beginning January 1,
2025, Medicaid rates for supportive living services must be at
least 54.75% of the average total nursing facility per diem
rate for the geographic areas defined by the Department and
shall include all add-ons for nursing facilities for the
geographic area provided for in Section 5-5.2.
(c) The Department may adopt rules to implement this
Section. Rules that establish or modify the services,
standards, and conditions for participation in the program
shall be adopted by the Department in consultation with the

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Department on Aging, the Department of Rehabilitation
Services, and the Department of Mental Health and
Developmental Disabilities (or their successor agencies).
(d) Subject to federal approval by the Centers for
Medicare and Medicaid Services, the Department shall accept
for consideration of certification under the program any
application for a site or building where distinct parts of the
site or building are designated for purposes other than the
provision of supportive living services, but only if:
(1) those distinct parts of the site or building are
not designated for the purpose of providing assisted
living services as required under the Assisted Living and
Shared Housing Act;
(2) those distinct parts of the site or building are
completely separate from the part of the building used for
the provision of supportive living program services,
including separate entrances;
(3) those distinct parts of the site or building do
not share any common spaces with the part of the building
used for the provision of supportive living program
services; and
(4) those distinct parts of the site or building do
not share staffing with the part of the building used for
the provision of supportive living program services.
(e) Facilities or distinct parts of facilities which are
selected as supportive living facilities and are in good

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standing with the Department's rules are exempt from the
provisions of the Nursing Home Care Act and the Illinois
Health Facilities Planning Act.
(f) Section 9817 of the American Rescue Plan Act of 2021
(Public Law 117-2) authorizes a 10% enhanced federal medical
assistance percentage for supportive living services for a
12-month period from April 1, 2021 through March 31, 2022.
Subject to federal approval, including the approval of any
necessary waiver amendments or other federally required
documents or assurances, for a 12-month period the Department
must pay a supplemental $26 per diem rate to all supportive
living facilities with the additional federal financial
participation funds that result from the enhanced federal
medical assistance percentage from April 1, 2021 through March
31, 2022. The Department may issue parameters around how the
supplemental payment should be spent, including quality
improvement activities. The Department may alter the form,
methods, or timeframes concerning the supplemental per diem
rate to comply with any subsequent changes to federal law,
changes made by guidance issued by the federal Centers for
Medicare and Medicaid Services, or other changes necessary to
receive the enhanced federal medical assistance percentage.
(g) All applications for the expansion of supportive
living dementia care settings involving sites not approved by
the Department by January 1, 2024 may allow new elderly
non-dementia units in addition to new dementia care units. The

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Department may approve such applications only if the
application has: (1) no more than one non-dementia care unit
for each dementia care unit and (2) the site is not located
within 4 miles of an existing supportive living program site
in Cook County (including the City of Chicago), not located
within 12 miles of an existing supportive living program site
in Alexander, Bond, Boone, Calhoun, Champaign, Clinton,
DeKalb, DuPage, Fulton, Grundy, Henry, Jackson, Jersey,
Johnson, Kane, Kankakee, Kendall, Lake, Macon, Macoupin,
Madison, Marshall, McHenry, McLean, Menard, Mercer, Monroe,
Peoria, Piatt, Rock Island, Sangamon, Stark, St. Clair,
Tazewell, Vermilion, Will, Williamson, Winnebago, or Woodford
counties, or not located within 25 miles of an existing
supportive living program site in any other county.
(g-5) Subject to federal approval, beginning January 1,
2027, any individual age 44 to 64 who is diagnosed as having
Alzheimer's disease or a related dementia and is determined to
be a person with a disability by the Social Security
Administration shall be eligible for services in a supportive
living dementia care setting if the individual meets all other
eligibility requirements to receive services in a supportive
living dementia care setting under 89 Ill. Adm. Code 146
Subpart B and E. The Department shall apply for any federal
waiver necessary to implement this subsection.
(h) Beginning January 1, 2025, subject to federal
approval, for a person who is a resident of a supportive living

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facility under this Section, the monthly personal needs
allowance shall be $120 per month.
(i) As stated in the supportive living program home and
community-based service waiver approved by the federal Centers
for Medicare and Medicaid Services, and beginning July 1,
2025, the Department must maintain the rate add-on implemented
on January 1, 2023 for the provision of 2 meals per day at no
less than $6.15 per day.
(j) Subject to federal approval, the Department shall
allow a certified medication aide to administer medication in
a supportive living facility. For purposes of this subsection,
"certified medication aide" means a person who has met the
qualifications for certification under Section 79 of the
Assisted Living and Shared Housing Act and assists with
medication administration while under the supervision of a
registered professional nurse as authorized by Section 50-75
of the Nurse Practice Act. The Department may adopt rules to
implement this subsection.
(Source: P.A. 103-102, Article 20, Section 20-5, eff. 1-1-24;
103-102, Article 100, Section 100-5, eff. 1-1-24; 103-593,
Article 15, Section 15-5, eff. 6-7-24; 103-593, Article 100,
Section 100-5, eff. 6-7-24; 103-593, Article 165, Section
165-5, eff. 6-7-24; 103-605, eff. 7-1-24; 103-886, eff.
8-9-24; 104-9, eff. 6-16-25; 104-417, eff. 8-15-25; revised
9-12-25.)

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ARTICLE 257.
Section 257-3. The Department of Public Health Powers and
Duties Law is amended by adding Section 2310-716 as follows:
(20 ILCS 2310/2310-716 new)
Sec. 2310-716. Report on patient access and care. With a
health care landscape shifting dramatically from inpatient,
volume-drive care to more outpatient, community-faced care and
further exacerbated by HR1 changes that disinvests billions of
dollars from the health care system and increase uninsured
populations, the Department of Public Health, in partnership
with relevant State agencies and with the advice of
stakeholders and experts in the field, shall develop a
comprehensive report that identifies how the resources of the
State and other health care payers may be optimized to protect
communities' and patients' access and care and to improve
Illinois' population health outcomes.
The Department may engage a third-party experienced and
expert research entity to develop this report. The report
shall include analysis, findings, and recommendations to
reform and strengthen the health care system in Illinois. The
report will have emphasis on the needs and vulnerabilities
experienced by individuals living in communities with limited
access to critical health care services.
The report will include epidemiological analyses and

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recommendations on policy and resource strategies to protect
and improve population health outcomes and health care access
including but not limited to:
(1) Patient experience that includes social needs
integration, reduced administrative burden, and enhanced
digital tools.
(2) Care model transformation that emphasizes
continuous, community-based care built to address health
access gaps and needs.
(3) Workforce resilience and optimization that
highlights partnership and care-delivery opportunities
across institutions.
(4) System agility to absorb and recover from
unforeseen public health crises and other external
factors.
The Department shall have access to all the necessary data
from State agencies as well as health care facilities as
required to inform on these recommendations, within the bounds
of relevance to their mission. Health care facilities will
hereby be directed to provide the necessary data to the
Department.
The Department shall issue recommendations to the General
Assembly and the Governor no later than January 31, 2027,
including proposed statutory or administrative changes
necessary to strengthen health care access, quality, and
effectiveness.

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(20 ILCS 2310/2310-715 rep.)
Section 257-5. The Department of Public Health Powers and
Duties Law of the Civil Administrative Code of Illinois is
amended by repealing Section 2310-715.
Section 257-10. The Illinois Public Aid Code is amended by
changing Sections 5A-2, 5A-7, 5A-8, and 12-4.25 as follows:
(305 ILCS 5/5A-2) (from Ch. 23, par. 5A-2)
Sec. 5A-2. Assessment.
(a)(1) Subject to Sections 5A-3 and 5A-10, for State
fiscal years 2009 through 2018, or as long as continued under
Section 5A-16, an annual assessment on inpatient services is
imposed on each hospital provider in an amount equal to
$218.38 multiplied by the difference of the hospital's
occupied bed days less the hospital's Medicare bed days,
provided, however, that the amount of $218.38 shall be
increased by a uniform percentage to generate an amount equal
to 75% of the State share of the payments authorized under
Section 5A-12.5, with such increase only taking effect upon
the date that a State share for such payments is required under
federal law. For the period of April through June 2015, the
amount of $218.38 used to calculate the assessment under this
paragraph shall, by emergency rule under subsection (s) of
Section 5-45 of the Illinois Administrative Procedure Act, be

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increased by a uniform percentage to generate $20,250,000 in
the aggregate for that period from all hospitals subject to
the annual assessment under this paragraph.
(2) In addition to any other assessments imposed under
this Article, effective July 1, 2016 and semi-annually
thereafter through June 2018, or as provided in Section 5A-16,
in addition to any federally required State share as
authorized under paragraph (1), the amount of $218.38 shall be
increased by a uniform percentage to generate an amount equal
to 75% of the ACA Assessment Adjustment, as defined in
subsection (b-6) of this Section.
For State fiscal years 2009 through 2018, or as provided
in Section 5A-16, a hospital's occupied bed days and Medicare
bed days shall be determined using the most recent data
available from each hospital's 2005 Medicare cost report as
contained in the Healthcare Cost Report Information System
file, for the quarter ending on December 31, 2006, without
regard to any subsequent adjustments or changes to such data.
If a hospital's 2005 Medicare cost report is not contained in
the Healthcare Cost Report Information System, then the
Illinois Department may obtain the hospital provider's
occupied bed days and Medicare bed days from any source
available, including, but not limited to, records maintained
by the hospital provider, which may be inspected at all times
during business hours of the day by the Illinois Department or
its duly authorized agents and employees.

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(3) Subject to Sections 5A-3, 5A-10, and 5A-16, for State
fiscal years 2019 and 2020, an annual assessment on inpatient
services is imposed on each hospital provider in an amount
equal to $197.19 multiplied by the difference of the
hospital's occupied bed days less the hospital's Medicare bed
days. For State fiscal years 2019 and 2020, a hospital's
occupied bed days and Medicare bed days shall be determined
using the most recent data available from each hospital's 2015
Medicare cost report as contained in the Healthcare Cost
Report Information System file, for the quarter ending on
March 31, 2017, without regard to any subsequent adjustments
or changes to such data. If a hospital's 2015 Medicare cost
report is not contained in the Healthcare Cost Report
Information System, then the Illinois Department may obtain
the hospital provider's occupied bed days and Medicare bed
days from any source available, including, but not limited to,
records maintained by the hospital provider, which may be
inspected at all times during business hours of the day by the
Illinois Department or its duly authorized agents and
employees. Notwithstanding any other provision in this
Article, for a hospital provider that did not have a 2015
Medicare cost report, but paid an assessment in State fiscal
year 2018 on the basis of hypothetical data, that assessment
amount shall be used for State fiscal years 2019 and 2020.
(4) Subject to Sections 5A-3 and 5A-10 and to subsection
(b-8), for the period of July 1, 2020 through December 31, 2020

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and calendar years 2021 through 2024, an annual assessment on
inpatient services is imposed on each hospital provider in an
amount equal to $221.50 multiplied by the difference of the
hospital's occupied bed days less the hospital's Medicare bed
days, provided however: for the period of July 1, 2020 through
December 31, 2020, (i) the assessment shall be equal to 50% of
the annual amount; and (ii) the amount of $221.50 shall be
retroactively adjusted by a uniform percentage to generate an
amount equal to 50% of the Assessment Adjustment, as defined
in subsection (b-7). For the period of July 1, 2020 through
December 31, 2020 and calendar years 2021 through 2024, a
hospital's occupied bed days and Medicare bed days shall be
determined using the most recent data available from each
hospital's 2015 Medicare cost report as contained in the
Healthcare Cost Report Information System file, for the
quarter ending on March 31, 2017, without regard to any
subsequent adjustments or changes to such data. If a
hospital's 2015 Medicare cost report is not contained in the
Healthcare Cost Report Information System, then the Illinois
Department may obtain the hospital provider's occupied bed
days and Medicare bed days from any source available,
including, but not limited to, records maintained by the
hospital provider, which may be inspected at all times during
business hours of the day by the Illinois Department or its
duly authorized agents and employees. Should the change in the
assessment methodology for fiscal years 2021 through December

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31, 2022 not be approved on or before June 30, 2020, the
assessment and payments under this Article in effect for
fiscal year 2020 shall remain in place until the new
assessment is approved. If the assessment methodology for July
1, 2020 through December 31, 2022, is approved on or after July
1, 2020, it shall be retroactive to July 1, 2020, subject to
federal approval and provided that the payments authorized
under Section 5A-12.7 have the same effective date as the new
assessment methodology. In giving retroactive effect to the
assessment approved after June 30, 2020, credit toward the new
assessment shall be given for any payments of the previous
assessment for periods after June 30, 2020. Notwithstanding
any other provision of this Article, for a hospital provider
that did not have a 2015 Medicare cost report, but paid an
assessment in State Fiscal Year 2020 on the basis of
hypothetical data, the data that was the basis for the 2020
assessment shall be used to calculate the assessment under
this paragraph until December 31, 2023. Beginning July 1, 2022
and through December 31, 2024, a safety-net hospital that had
a change of ownership in calendar year 2021, and whose
inpatient utilization had decreased by 90% from the prior year
and prior to the change of ownership, may be eligible to pay a
tax based on hypothetical data based on a determination of
financial distress by the Department. Subject to federal
approval, the Department may, by January 1, 2024, develop a
hypothetical tax for a specialty cancer hospital which had a

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structural change of ownership during calendar year 2022 from
a for-profit entity to a non-profit entity, and which has
experienced a decline of 60% or greater in inpatient days of
care as compared to the prior owners 2015 Medicare cost
report. This change of ownership may make the hospital
eligible for a hypothetical tax under the new hospital
provision of the assessment defined in this Section. This new
hypothetical tax may be applicable from January 1, 2024
through December 31, 2026.
(5) Subject to Sections 5A-3 and 5A-10, beginning January
1, 2025, an annual assessment on inpatient services is imposed
on each hospital provider in an amount equal to $362, or any
reduction thereof in accordance with this subsection,
multiplied by the difference of the hospital's occupied bed
days less the hospital's Medicare bed days; however, the rate
shall be $221.50 until the Department receives federal
approval and implements the reimbursement rates in subsection
(r) of Section 5A-12.7. The Department may bill for the
difference between the assessment rate of $362, or any
reduction thereof in accordance with this subsection, and
$221.50 no earlier than 17 calendar days after implementing
the reimbursement rates in subsection (r) of Section 5A-12.7.
(A) Upon receiving federal approval for the
reimbursement rates in subsection (r) of Section 5A-12.7,
the Department shall bill the hospital for the incremental
difference in total tax due resulting from the increase

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provided in this subsection for the number of months from
January 1, 2025 through the date of federal approval. The
amount shall be due and payable no later than December 31,
2025 and no earlier than 17 calendar days after
implementing the reimbursement rates in subsection (r) of
Section 5A-12.7. The Department shall bill hospitals in
the same proportional rate as the Department has
implemented the inpatient reimbursement rates in
subsection (r) of Section 5A-12.7.
(B) Beginning January 1, 2025, a hospital's occupied
bed days and Medicare bed days shall be determined using
the most recent data available from each hospital's 2015
Medicare cost report as contained in the Healthcare Cost
Report Information System file, for the quarter ending on
March 31, 2017, without regard to any subsequent
adjustments or changes to such data. If a hospital's 2015
Medicare cost report is not contained in the Healthcare
Cost Report Information System, then the Department may
obtain the hospital provider's occupied bed days and
Medicare bed days from any source available, including,
but not limited to, records maintained by the hospital
provider, which may be inspected at all times during
business hours of the day by the Department or its duly
authorized agents and employees. If the reimbursement
rates in subsection (r) of Section 5A-12.7 require
reduction to comply with federal spending limits, then the

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tax rate of $362 shall be reduced, in accordance with
subsection (s) of Section 5A-12.7, by the same percentage
reduction to payments required to comply with federal
spending limits.
(6) For calendar year 2026, and for each year thereafter
in which a tax is imposed under this Section, the Department
may seek to obtain a waiver from the federal Centers for
Medicare and Medicaid Services of the uniformity requirements
in place for the tax imposed under this Section, provided that
such waiver request does not risk the assessment imposed or
payments authorized under this Section from continuing. Such
uniformity requirements shall only be waived for
not-for-profit hospitals operating as a freestanding cancer
hospital that have contracted to provide services to members
served by at least 50% of the managed care organizations
contracted with the Department. Such tax rates imposed on a
hospital shall be no more than 50% and no less than 25% of the
tax imposed on all other hospitals in this State unless
different rates are necessary to meet federal statistical
tests necessary for continued federal financial participation.
Upon federal approval of such a waiver, other tax rates
imposed under this Article shall be adjusted to ensure budget
neutrality.
(b) (Blank).
(b-5)(1) Subject to Sections 5A-3 and 5A-10, for the
portion of State fiscal year 2012, beginning June 10, 2012

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through June 30, 2012, and for State fiscal years 2013 through
2018, or as provided in Section 5A-16, an annual assessment on
outpatient services is imposed on each hospital provider in an
amount equal to .008766 multiplied by the hospital's
outpatient gross revenue, provided, however, that the amount
of .008766 shall be increased by a uniform percentage to
generate an amount equal to 25% of the State share of the
payments authorized under Section 5A-12.5, with such increase
only taking effect upon the date that a State share for such
payments is required under federal law. For the period
beginning June 10, 2012 through June 30, 2012, the annual
assessment on outpatient services shall be prorated by
multiplying the assessment amount by a fraction, the numerator
of which is 21 days and the denominator of which is 365 days.
For the period of April through June 2015, the amount of
.008766 used to calculate the assessment under this paragraph
shall, by emergency rule under subsection (s) of Section 5-45
of the Illinois Administrative Procedure Act, be increased by
a uniform percentage to generate $6,750,000 in the aggregate
for that period from all hospitals subject to the annual
assessment under this paragraph.
(2) In addition to any other assessments imposed under
this Article, effective July 1, 2016 and semi-annually
thereafter through June 2018, in addition to any federally
required State share as authorized under paragraph (1), the
amount of .008766 shall be increased by a uniform percentage

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to generate an amount equal to 25% of the ACA Assessment
Adjustment, as defined in subsection (b-6) of this Section.
For the portion of State fiscal year 2012, beginning June
10, 2012 through June 30, 2012, and State fiscal years 2013
through 2018, or as provided in Section 5A-16, a hospital's
outpatient gross revenue shall be determined using the most
recent data available from each hospital's 2009 Medicare cost
report as contained in the Healthcare Cost Report Information
System file, for the quarter ending on June 30, 2011, without
regard to any subsequent adjustments or changes to such data.
If a hospital's 2009 Medicare cost report is not contained in
the Healthcare Cost Report Information System, then the
Department may obtain the hospital provider's outpatient gross
revenue from any source available, including, but not limited
to, records maintained by the hospital provider, which may be
inspected at all times during business hours of the day by the
Department or its duly authorized agents and employees.
(3) Subject to Sections 5A-3, 5A-10, and 5A-16, for State
fiscal years 2019 and 2020, an annual assessment on outpatient
services is imposed on each hospital provider in an amount
equal to .01358 multiplied by the hospital's outpatient gross
revenue. For State fiscal years 2019 and 2020, a hospital's
outpatient gross revenue shall be determined using the most
recent data available from each hospital's 2015 Medicare cost
report as contained in the Healthcare Cost Report Information
System file, for the quarter ending on March 31, 2017, without

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regard to any subsequent adjustments or changes to such data.
If a hospital's 2015 Medicare cost report is not contained in
the Healthcare Cost Report Information System, then the
Department may obtain the hospital provider's outpatient gross
revenue from any source available, including, but not limited
to, records maintained by the hospital provider, which may be
inspected at all times during business hours of the day by the
Department or its duly authorized agents and employees.
Notwithstanding any other provision in this Article, for a
hospital provider that did not have a 2015 Medicare cost
report, but paid an assessment in State fiscal year 2018 on the
basis of hypothetical data, that assessment amount shall be
used for State fiscal years 2019 and 2020.
(4) Subject to Sections 5A-3 and 5A-10 and to subsection
(b-8), for the period of July 1, 2020 through December 31, 2020
and calendar years 2021 through 2024, an annual assessment on
outpatient services is imposed on each hospital provider in an
amount equal to .01525 multiplied by the hospital's outpatient
gross revenue, provided however: (i) for the period of July 1,
2020 through December 31, 2020, the assessment shall be equal
to 50% of the annual amount; and (ii) the amount of .01525
shall be retroactively adjusted by a uniform percentage to
generate an amount equal to 50% of the Assessment Adjustment,
as defined in subsection (b-7). For the period of July 1, 2020
through December 31, 2020 and calendar years 2021 through
2024, a hospital's outpatient gross revenue shall be

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determined using the most recent data available from each
hospital's 2015 Medicare cost report as contained in the
Healthcare Cost Report Information System file, for the
quarter ending on March 31, 2017, without regard to any
subsequent adjustments or changes to such data. If a
hospital's 2015 Medicare cost report is not contained in the
Healthcare Cost Report Information System, then the Illinois
Department may obtain the hospital provider's outpatient
revenue data from any source available, including, but not
limited to, records maintained by the hospital provider, which
may be inspected at all times during business hours of the day
by the Illinois Department or its duly authorized agents and
employees. Should the change in the assessment methodology
above for fiscal years 2021 through calendar year 2022 not be
approved prior to July 1, 2020, the assessment and payments
under this Article in effect for fiscal year 2020 shall remain
in place until the new assessment is approved. If the change in
the assessment methodology above for July 1, 2020 through
December 31, 2022, is approved after June 30, 2020, it shall
have a retroactive effective date of July 1, 2020, subject to
federal approval and provided that the payments authorized
under Section 12A-7 have the same effective date as the new
assessment methodology. In giving retroactive effect to the
assessment approved after June 30, 2020, credit toward the new
assessment shall be given for any payments of the previous
assessment for periods after June 30, 2020. Notwithstanding

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any other provision of this Article, for a hospital provider
that did not have a 2015 Medicare cost report, but paid an
assessment in State Fiscal Year 2020 on the basis of
hypothetical data, the data that was the basis for the 2020
assessment shall be used to calculate the assessment under
this paragraph until December 31, 2023. Beginning July 1, 2022
and through December 31, 2024, a safety-net hospital that had
a change of ownership in calendar year 2021, and whose
inpatient utilization had decreased by 90% from the prior year
and prior to the change of ownership, may be eligible to pay a
tax based on hypothetical data based on a determination of
financial distress by the Department.
(5) Subject to Sections 5A-3 and 5A-10, beginning January
1, 2025, an annual assessment on outpatient services is
imposed on each hospital provider in an amount equal to
.03273, or any reduction thereof in accordance with this
subsection, multiplied by the hospital's outpatient gross
revenue; however the rate shall remain .01525, until the
Department receives federal approval and implements the
reimbursement rates of payment in subsection (r) of Section
5A-12.7. The Department may bill for the difference between
the assessment multiplier of .03273 and .01525 no earlier than
17 calendar days after the first payment based on the
reimbursement rates in subsection (r) of Section 5A-12.7.
(A) Upon receiving federal approval for the
reimbursement rates in subsection (r) of Section 5A-12.7,

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the Department shall bill the hospital for the incremental
difference in total tax due resulting from the increase
provided in this subsection for the number of months from
January 1, 2025 through the date of federal approval. The
amount shall be due and payable no later than December 31,
2025 and no earlier than 17 calendar days after
implementing the reimbursement rates in subsection (r) of
Section 5A-12.7. The Department shall bill hospitals in
the same proportional rate as the Department has
implemented the outpatient reimbursement rates in
subsection (r) of Section 5A-12.7.
(B) Beginning January 1, 2025, a hospital's outpatient
gross revenue shall be determined using the most recent
data available from each hospital's 2015 Medicare cost
report as contained in the Healthcare Cost Report
Information System file, for the quarter ending on March
31, 2017, without regard to any subsequent adjustments or
changes to such data. If a hospital's 2015 Medicare cost
report is not contained in the Healthcare Cost Report
Information System, then the Department may obtain the
hospital provider's outpatient revenue data from any
source available, including, but not limited to, records
maintained by the hospital provider, which may be
inspected at all times during business hours of the day by
the Department or its duly authorized agents and
employees. If the reimbursement rates in subsection (r) of

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Section 5A-12.7 require reduction to comply with federal
spending limits, then the tax rate of .03273 shall be
reduced, in accordance with subsection (s) of Section
5A-12.7, by the same percentage reduction to payments
required to comply with federal spending limits.
(6) For calendar year 2026, and for each year thereafter
in which a tax is imposed under this Section, the Department
may seek to obtain a waiver from the federal Centers for
Medicare and Medicaid Services of the uniformity requirements
in place for the tax imposed under this Section, provided that
such waiver request does not risk the assessment imposed or
payments authorized under this Section from continuing. Such
uniformity requirements shall only be waived for
not-for-profit hospitals operating as a freestanding cancer
hospital that have contracted to provide services to members
served by at least 50% of the managed care organizations
contracted with the Department. Such tax rates imposed on a
hospital shall be no more than 50% and no less than 25% of the
tax imposed on all other hospitals in this State unless
different rates are necessary to meet federal statistical
tests necessary for continued federal financial participation.
Upon federal approval of such a waiver, other tax rates
imposed under this Article shall be adjusted to ensure budget
neutrality.
(b-6)(1) As used in this Section, "ACA Assessment
Adjustment" means:

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(A) For the period of July 1, 2016 through December
31, 2016, the product of .19125 multiplied by the sum of
the fee-for-service payments to hospitals as authorized
under Section 5A-12.5 and the adjustments authorized under
subsection (t) of Section 5A-12.2 to managed care
organizations for hospital services due and payable in the
month of April 2016 multiplied by 6.
(B) For the period of January 1, 2017 through June 30,
2017, the product of .19125 multiplied by the sum of the
fee-for-service payments to hospitals as authorized under
Section 5A-12.5 and the adjustments authorized under
subsection (t) of Section 5A-12.2 to managed care
organizations for hospital services due and payable in the
month of October 2016 multiplied by 6, except that the
amount calculated under this subparagraph (B) shall be
adjusted, either positively or negatively, to account for
the difference between the actual payments issued under
Section 5A-12.5 for the period beginning July 1, 2016
through December 31, 2016 and the estimated payments due
and payable in the month of April 2016 multiplied by 6 as
described in subparagraph (A).
(C) For the period of July 1, 2017 through December
31, 2017, the product of .19125 multiplied by the sum of
the fee-for-service payments to hospitals as authorized
under Section 5A-12.5 and the adjustments authorized under
subsection (t) of Section 5A-12.2 to managed care

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organizations for hospital services due and payable in the
month of April 2017 multiplied by 6, except that the
amount calculated under this subparagraph (C) shall be
adjusted, either positively or negatively, to account for
the difference between the actual payments issued under
Section 5A-12.5 for the period beginning January 1, 2017
through June 30, 2017 and the estimated payments due and
payable in the month of October 2016 multiplied by 6 as
described in subparagraph (B).
(D) For the period of January 1, 2018 through June 30,
2018, the product of .19125 multiplied by the sum of the
fee-for-service payments to hospitals as authorized under
Section 5A-12.5 and the adjustments authorized under
subsection (t) of Section 5A-12.2 to managed care
organizations for hospital services due and payable in the
month of October 2017 multiplied by 6, except that:
(i) the amount calculated under this subparagraph
(D) shall be adjusted, either positively or
negatively, to account for the difference between the
actual payments issued under Section 5A-12.5 for the
period of July 1, 2017 through December 31, 2017 and
the estimated payments due and payable in the month of
April 2017 multiplied by 6 as described in
subparagraph (C); and
(ii) the amount calculated under this subparagraph
(D) shall be adjusted to include the product of .19125

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multiplied by the sum of the fee-for-service payments,
if any, estimated to be paid to hospitals under
subsection (b) of Section 5A-12.5.
(2) The Department shall complete and apply a final
reconciliation of the ACA Assessment Adjustment prior to June
30, 2018 to account for:
(A) any differences between the actual payments issued
or scheduled to be issued prior to June 30, 2018 as
authorized in Section 5A-12.5 for the period of January 1,
2018 through June 30, 2018 and the estimated payments due
and payable in the month of October 2017 multiplied by 6 as
described in subparagraph (D); and
(B) any difference between the estimated
fee-for-service payments under subsection (b) of Section
5A-12.5 and the amount of such payments that are actually
scheduled to be paid.
The Department shall notify hospitals of any additional
amounts owed or reduction credits to be applied to the June
2018 ACA Assessment Adjustment. This is to be considered the
final reconciliation for the ACA Assessment Adjustment.
(3) Notwithstanding any other provision of this Section,
if for any reason the scheduled payments under subsection (b)
of Section 5A-12.5 are not issued in full by the final day of
the period authorized under subsection (b) of Section 5A-12.5,
funds collected from each hospital pursuant to subparagraph
(D) of paragraph (1) and pursuant to paragraph (2),

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attributable to the scheduled payments authorized under
subsection (b) of Section 5A-12.5 that are not issued in full
by the final day of the period attributable to each payment
authorized under subsection (b) of Section 5A-12.5, shall be
refunded.
(4) The increases authorized under paragraph (2) of
subsection (a) and paragraph (2) of subsection (b-5) shall be
limited to the federally required State share of the total
payments authorized under Section 5A-12.5 if the sum of such
payments yields an annualized amount equal to or less than
$450,000,000, or if the adjustments authorized under
subsection (t) of Section 5A-12.2 are found not to be
actuarially sound; however, this limitation shall not apply to
the fee-for-service payments described in subsection (b) of
Section 5A-12.5.
(b-7)(1) As used in this Section, "Assessment Adjustment"
means:
(A) For the period of July 1, 2020 through December
31, 2020, the product of .3853 multiplied by the total of
the actual payments made under subsections (c) through (k)
of Section 5A-12.7 attributable to the period, less the
total of the assessment imposed under subsections (a) and
(b-5) of this Section for the period.
(B) For each calendar quarter beginning January 1,
2021 through December 31, 2022, the product of .3853
multiplied by the total of the actual payments made under

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subsections (c) through (k) of Section 5A-12.7
attributable to the period, less the total of the
assessment imposed under subsections (a) and (b-5) of this
Section for the period.
(C) Beginning on January 1, 2023, and each subsequent
July 1 and January 1, the product of .3853 multiplied by
the total of the actual payments made under subsections
(c) through (j) and subsection (r) of Section 5A-12.7
attributable to the 6-month period immediately preceding
the period to which the adjustment applies, less the total
of the assessment imposed under subsections (a) and (b-5)
of this Section for the 6-month period immediately
preceding the period to which the adjustment applies.
(D) For the 6-month tax adjustment period beginning
July 1, 2026, the Assessment Adjustment defined in
subparagraph (C) of this paragraph (1) shall be half of
the amount calculated under subparagraph (C) of this
paragraph (1).
(2) The Department shall calculate and notify each
hospital of the total Assessment Adjustment and any additional
assessment owed by the hospital or refund owed to the hospital
on either a semi-annual or annual basis. Such notice shall be
issued at least 30 days prior to any period in which the
assessment will be adjusted. Any additional assessment owed by
the hospital or refund owed to the hospital shall be uniformly
applied to the assessment owed by the hospital in monthly

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installments for the subsequent semi-annual period or calendar
year. If no assessment is owed in the subsequent year, any
amount owed by the hospital or refund due to the hospital,
shall be paid in a lump sum. If the calculation that is
computed under this Section could result in a decrease in the
Department's federal financial participation percentage for
payments authorized under Section 5A-12.7, then the Department
shall instead apply a uniform percentage reduction to the
payment rates outlined in subsection (r) of Section 5A-12.7
for all classes as defined in subsections (g) and (h) of
Section 5A-12.7 by an amount no more than necessary to
maximize federal reimbursement.
(3) The Department shall publish all details of the
Assessment Adjustment calculation performed each year on its
website within 30 days of completing the calculation, and also
submit the details of the Assessment Adjustment calculation as
part of the Department's annual report to the General
Assembly.
(b-8) Notwithstanding any other provision of this Article,
the Department shall reduce the assessments imposed on each
hospital under subsections (a) and (b-5) by the uniform
percentage necessary to reduce the total assessment imposed on
all hospitals by an aggregate amount of $240,000,000, with
such reduction being applied by June 30, 2022. The assessment
reduction required for each hospital under this subsection
shall be forever waived, forgiven, and released by the

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Department.
(c) (Blank).
(d) Notwithstanding any of the other provisions of this
Section, the Department is authorized to adopt rules to reduce
the rate of any annual assessment imposed under this Section,
as authorized by Section 5-46.2 of the Illinois Administrative
Procedure Act.
(e) Notwithstanding any other provision of this Section,
any plan providing for an assessment on a hospital provider as
a permissible tax under Title XIX of the federal Social
Security Act and Medicaid-eligible payments to hospital
providers from the revenues derived from that assessment shall
be reviewed by the Illinois Department of Healthcare and
Family Services, as the Single State Medicaid Agency required
by federal law, to determine whether those assessments and
hospital provider payments meet federal Medicaid standards. If
the Department determines that the elements of the plan may
meet federal Medicaid standards and a related State Medicaid
Plan Amendment is prepared in a manner and form suitable for
submission, that State Plan Amendment shall be submitted in a
timely manner for review by the Centers for Medicare and
Medicaid Services of the United States Department of Health
and Human Services and subject to approval by the Centers for
Medicare and Medicaid Services of the United States Department
of Health and Human Services. No such plan shall become
effective without approval by the Illinois General Assembly by

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the enactment into law of related legislation. Notwithstanding
any other provision of this Section, the Department is
authorized to adopt rules to reduce the rate of any annual
assessment imposed under this Section. Any such rules may be
adopted by the Department under Section 5-50 of the Illinois
Administrative Procedure Act.
(f) To provide for the expeditious and timely
implementation of the changes made to this Section by Public
Act 104-7 this amendatory Act of the 104th General Assembly,
the Department may adopt emergency rules as authorized by
Section 5-45 of the Illinois Administrative Procedure Act. The
adoption of emergency rules is deemed to be necessary for the
public interest, safety, and welfare.
(Source: P.A. 103-102, eff. 1-1-24; 104-7, eff. 6-16-25;
104-9, eff. 6-16-25; revised 8-5-25.)
(305 ILCS 5/5A-7) (from Ch. 23, par. 5A-7)
Sec. 5A-7. Administration; enforcement provisions.
(a) The Illinois Department shall establish and maintain a
listing of all hospital providers appearing in the licensing
records of the Illinois Department of Public Health, which
shall show each provider's name and principal place of
business and the name and address of each hospital operated,
conducted, or maintained by the provider in this State. The
listing shall also include the monthly assessment amounts owed
for each hospital and any unpaid assessment liability greater

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than 90 days delinquent. The Illinois Department shall
administer and enforce this Article and collect the
assessments and penalty assessments imposed under this Article
using procedures employed in its administration of this Code
generally. The Illinois Department, its Director, and every
hospital provider subject to assessment under this Article
shall have the following powers, duties, and rights:
(1) The Illinois Department may initiate either
administrative or judicial proceedings, or both, to
enforce provisions of this Article. Administrative
enforcement proceedings initiated hereunder shall be
governed by the Illinois Department's administrative
rules. Judicial enforcement proceedings initiated
hereunder shall be governed by the rules of procedure
applicable in the courts of this State.
(2) (Blank).
(3) Any unpaid assessment under this Article shall
become a lien upon the assets of the hospital upon which it
was assessed. If any hospital provider, outside the usual
course of its business, sells or transfers the major part
of any one or more of (A) the real property and
improvements, (B) the machinery and equipment, or (C) the
furniture or fixtures, of any hospital that is subject to
the provisions of this Article, the seller or transferor
shall pay the Illinois Department the amount of any
assessment, assessment penalty, and interest (if any) due

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from it under this Article up to the date of the sale or
transfer. The Illinois Department may, in its discretion,
foreclose on such a lien, but shall do so in a manner that
is consistent with Section 5e of the Retailers' Occupation
Tax Act. If the seller or transferor fails to pay any
assessment, assessment penalty, and interest (if any) due,
the purchaser or transferee of such asset shall be liable
for the amount of the assessment, penalties, and interest
(if any) up to the amount of the reasonable value of the
property acquired by the purchaser or transferee. The
purchaser or transferee shall continue to be liable until
the purchaser or transferee pays the full amount of the
assessment, penalties, and interest (if any) up to the
amount of the reasonable value of the property acquired by
the purchaser or transferee or until the purchaser or
transferee receives from the Illinois Department a
certificate showing that such assessment, penalty, and
interest have been paid or a certificate from the Illinois
Department showing that no assessment, penalty, or
interest is due from the seller or transferor under this
Article.
(4) Payments under this Article are not subject to the
Illinois Prompt Payment Act. Credits or refunds shall not
bear interest.
(b) In addition to any other remedy provided for and
without sending a notice of assessment liability, the Illinois

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Department shall collect an unpaid assessment by withholding,
as payment of the assessment, reimbursements or other amounts
otherwise payable by the Illinois Department to the hospital
provider, including, but not limited to, payment amounts
otherwise payable from a managed care organization performing
duties under contract with the Illinois Department. To the
extent not prohibited by federal or State law, the Department
may collect an unpaid assessment by offsetting or recouping,
as payment of the assessment obligation, amounts otherwise
payable by any State agency to the hospital provider,
including, but not limited to, State grants and grant
appropriations.
(1) The requirements of this subsection may be waived
in instances when a disaster proclamation has been
declared by the Governor. In such circumstances, a
hospital must demonstrate temporary financial distress and
establish an agreement with the Illinois Department
specifying when repayment in full of all taxes owed will
occur.
(2) The requirements of this subsection may be waived
by the Illinois Department in instances when a hospital
has entered into and remains in compliance with a
repayment plan or a tax deferral plan. A repayment plan or
tax deferral plan must be entered into no later than 30
days after notice of an unpaid assessment payment.
Beginning July 1, 2026, the Illinois Department shall not

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enter into any new tax deferral plan with a hospital. A
hospital may enter into a repayment plan with the
Department that includes terms for repayment of the total
amount owed over 72 months or less, repaid in equal
payment increments. Payments shall begin within 30 days of
the signed agreement date. Hospitals with existing
repayment agreements that were negotiated and remain in
effect prior to June 1, 2026 may either adhere to the terms
of their existing agreements or, alternatively, seek to
amend the existing agreement's repayment period to 72
months or less from the date the new agreement is entered
into. Renegotiated repayment plans shall include equal
payment increments for the total amount owed over the
period of the renegotiated agreement. Such renegotiated
repayment agreements may only include amendments to (a)
the length of the repayment period and (b) the payment
increments, provided that the total amount to be repaid
does not change from what remained unpaid under the
original repayment agreement and any additional amounts
owed. An existing repayment or tax deferral agreement
cannot be amended more than once unless otherwise agreed
upon by the Department. No repayment plan may exceed a
period of 36 months. No tax deferral plan may exceed a
period of 6 months, and repayment after the end of a tax
deferral plan shall not exceed 36 months. Failure to
remain in compliance with a repayment plan or tax deferral

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plan shall cause immediate termination of such plan unless
there is prior written consent from the Illinois
Department for a period of non-compliance.
(3) Beginning September 1, 2025, the Illinois
Department shall immediately collect all overdue unpaid
assessments and penalties through the collection methods
authorized under this Section, unless a repayment plan or
tax deferral plan has already been agreed to by September
1, 2025.
(4) For any unpaid assessments and penalties that are
overdue as of the effective date of this amendatory Act of
the 104th General Assembly of House Bill 2771 of the 104th
General Assembly, upon receipt of payment the Department
may, at its discretion, transfer funds from the Hospital
Provider Fund to the Healthcare Provider Relief Fund,
provided that, at the time of each transfer, there are no
outstanding assessment-related payments owed to hospitals
that cannot be paid from resources remaining in the
Hospital Provider Fund after the transfer.
(c) To provide for the expeditious and timely
implementation of the changes made to this Section by this
amendatory Act of the 104th General Assembly, the Department
may adopt emergency rules as authorized by Section 5-45 of the
Illinois Administrative Procedure Act. The adoption of
emergency rules is deemed to be necessary for the public
interest, safety, and welfare.

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(Source: P.A. 104-2, eff. 6-16-25; 104-7, eff. 6-16-25.)
(305 ILCS 5/12-4.25) (from Ch. 23, par. 12-4.25)
Sec. 12-4.25. Medical assistance program; vendor
participation.
(A) The Illinois Department may deny, suspend, or
terminate the eligibility of any person, firm, corporation,
association, agency, institution or other legal entity to
participate as a vendor of goods or services to recipients
under the medical assistance program under Article V, or may
exclude any such person or entity from participation as such a
vendor, and may deny, suspend, or recover payments, if after
reasonable notice and opportunity for a hearing the Illinois
Department finds:
(a) Such vendor is not complying with the Department's
policy or rules and regulations, or with the terms and
conditions prescribed by the Illinois Department in its
vendor agreement, which document shall be developed by the
Department as a result of negotiations with each vendor
category, including physicians, hospitals, long term care
facilities, pharmacists, optometrists, podiatric
physicians, and dentists setting forth the terms and
conditions applicable to the participation of each vendor
group in the program; or
(b) Such vendor has failed to keep or make available
for inspection, audit or copying, after receiving a

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written request from the Illinois Department, such records
regarding payments claimed for providing services. This
section does not require vendors to make available patient
records of patients for whom services are not reimbursed
under this Code; or
(c) Such vendor has failed to furnish any information
requested by the Department regarding payments for
providing goods or services; or
(d) Such vendor has knowingly made, or caused to be
made, any false statement or representation of a material
fact in connection with the administration of the medical
assistance program; or
(e) Such vendor has furnished goods or services to a
recipient which are (1) in excess of need, (2) harmful, or
(3) of grossly inferior quality, all of such
determinations to be based upon competent medical judgment
and evaluations; or
(f) The vendor; a person with management
responsibility for a vendor; an officer or person owning,
either directly or indirectly, 5% or more of the shares of
stock or other evidences of ownership in a corporate
vendor; an owner of a sole proprietorship which is a
vendor; or a partner in a partnership which is a vendor,
either:
(1) was previously terminated, suspended, or
excluded from participation in the Illinois medical

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assistance program, or was terminated, suspended, or
excluded from participation in another state or
federal medical assistance or health care program; or
(2) was a person with management responsibility
for a vendor previously terminated, suspended, or
excluded from participation in the Illinois medical
assistance program, or terminated, suspended, or
excluded from participation in another state or
federal medical assistance or health care program
during the time of conduct which was the basis for that
vendor's termination, suspension, or exclusion; or
(3) was an officer, or person owning, either
directly or indirectly, 5% or more of the shares of
stock or other evidences of ownership in a corporate
or limited liability company vendor previously
terminated, suspended, or excluded from participation
in the Illinois medical assistance program, or
terminated, suspended, or excluded from participation
in a state or federal medical assistance or health
care program during the time of conduct which was the
basis for that vendor's termination, suspension, or
exclusion; or
(4) was an owner of a sole proprietorship or
partner of a partnership previously terminated,
suspended, or excluded from participation in the
Illinois medical assistance program, or terminated,

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suspended, or excluded from participation in a state
or federal medical assistance or health care program
during the time of conduct which was the basis for that
vendor's termination, suspension, or exclusion; or
(f-1) Such vendor has a delinquent debt owed to the
Illinois Department; or
(g) The vendor; a person with management
responsibility for a vendor; an officer or person owning,
either directly or indirectly, 5% or more of the shares of
stock or other evidences of ownership in a corporate or
limited liability company vendor; an owner of a sole
proprietorship which is a vendor; or a partner in a
partnership which is a vendor, either:
(1) has engaged in practices prohibited by
applicable federal or State law or regulation; or
(2) was a person with management responsibility
for a vendor at the time that such vendor engaged in
practices prohibited by applicable federal or State
law or regulation; or
(3) was an officer, or person owning, either
directly or indirectly, 5% or more of the shares of
stock or other evidences of ownership in a vendor at
the time such vendor engaged in practices prohibited
by applicable federal or State law or regulation; or
(4) was an owner of a sole proprietorship or
partner of a partnership which was a vendor at the time

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such vendor engaged in practices prohibited by
applicable federal or State law or regulation; or
(h) The direct or indirect ownership of the vendor
(including the ownership of a vendor that is a sole
proprietorship, a partner's interest in a vendor that is a
partnership, or ownership of 5% or more of the shares of
stock or other evidences of ownership in a corporate
vendor) has been transferred by an individual who is
terminated, suspended, or excluded or barred from
participating as a vendor to the individual's spouse,
child, brother, sister, parent, grandparent, grandchild,
uncle, aunt, niece, nephew, cousin, or relative by
marriage.
(A-5) The Illinois Department may deny, suspend, or
terminate the eligibility of any person, firm, corporation,
association, agency, institution, or other legal entity to
participate as a vendor of goods or services to recipients
under the medical assistance program under Article V, or may
exclude any such person or entity from participation as such a
vendor, if, after reasonable notice and opportunity for a
hearing, the Illinois Department finds that the vendor; a
person with management responsibility for a vendor; an officer
or person owning, either directly or indirectly, 5% or more of
the shares of stock or other evidences of ownership in a
corporate vendor; an owner of a sole proprietorship that is a
vendor; or a partner in a partnership that is a vendor has been

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convicted of an offense based on fraud or willful
misrepresentation related to any of the following:
(1) The medical assistance program under Article V of
this Code.
(2) A medical assistance or health care program in
another state.
(3) The Medicare program under Title XVIII of the
Social Security Act.
(4) The provision of health care services.
(5) A violation of this Code, as provided in Article
VIIIA, or another state or federal medical assistance
program or health care program.
(A-10) The Illinois Department may deny, suspend, or
terminate the eligibility of any person, firm, corporation,
association, agency, institution, or other legal entity to
participate as a vendor of goods or services to recipients
under the medical assistance program under Article V, or may
exclude any such person or entity from participation as such a
vendor, if, after reasonable notice and opportunity for a
hearing, the Illinois Department finds that (i) the vendor,
(ii) a person with management responsibility for a vendor,
(iii) an officer or person owning, either directly or
indirectly, 5% or more of the shares of stock or other
evidences of ownership in a corporate vendor, (iv) an owner of
a sole proprietorship that is a vendor, or (v) a partner in a
partnership that is a vendor has been convicted of an offense

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related to any of the following:
(1) Murder.
(2) A Class X felony under the Criminal Code of 1961 or
the Criminal Code of 2012.
(3) Sexual misconduct that may subject recipients to
an undue risk of harm.
(4) A criminal offense that may subject recipients to
an undue risk of harm.
(5) A crime of fraud or dishonesty.
(6) A crime involving a controlled substance.
(7) A misdemeanor relating to fraud, theft,
embezzlement, breach of fiduciary responsibility, or other
financial misconduct related to a health care program.
(A-15) The Illinois Department may deny the eligibility of
any person, firm, corporation, association, agency,
institution, or other legal entity to participate as a vendor
of goods or services to recipients under the medical
assistance program under Article V if, after reasonable notice
and opportunity for a hearing, the Illinois Department finds:
(1) The applicant or any person with management
responsibility for the applicant; an officer or member of
the board of directors of an applicant; an entity owning
(directly or indirectly) 5% or more of the shares of stock
or other evidences of ownership in a corporate vendor
applicant; an owner of a sole proprietorship applicant; a
partner in a partnership applicant; or a technical or

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other advisor to an applicant has a debt owed to the
Illinois Department, and no payment arrangements
acceptable to the Illinois Department have been made by
the applicant.
(2) The applicant or any person with management
responsibility for the applicant; an officer or member of
the board of directors of an applicant; an entity owning
(directly or indirectly) 5% or more of the shares of stock
or other evidences of ownership in a corporate vendor
applicant; an owner of a sole proprietorship applicant; a
partner in a partnership vendor applicant; or a technical
or other advisor to an applicant was (i) a person with
management responsibility, (ii) an officer or member of
the board of directors of an applicant, (iii) an entity
owning (directly or indirectly) 5% or more of the shares
of stock or other evidences of ownership in a corporate
vendor, (iv) an owner of a sole proprietorship, (v) a
partner in a partnership vendor, (vi) a technical or other
advisor to a vendor, during a period of time where the
conduct of that vendor resulted in a debt owed to the
Illinois Department, and no payment arrangements
acceptable to the Illinois Department have been made by
that vendor.
(3) There is a credible allegation of the use,
transfer, or lease of assets of any kind to an applicant
from a current or prior vendor who has a debt owed to the

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Illinois Department, no payment arrangements acceptable to
the Illinois Department have been made by that vendor or
the vendor's alternate payee, and the applicant knows or
should have known of such debt.
(4) There is a credible allegation of a transfer of
management responsibilities, or direct or indirect
ownership, to an applicant from a current or prior vendor
who has a debt owed to the Illinois Department, and no
payment arrangements acceptable to the Illinois Department
have been made by that vendor or the vendor's alternate
payee, and the applicant knows or should have known of
such debt.
(5) There is a credible allegation of the use,
transfer, or lease of assets of any kind to an applicant
who is a spouse, child, brother, sister, parent,
grandparent, grandchild, uncle, aunt, niece, relative by
marriage, nephew, cousin, or relative of a current or
prior vendor who has a debt owed to the Illinois
Department and no payment arrangements acceptable to the
Illinois Department have been made.
(6) There is a credible allegation that the
applicant's previous affiliations with a provider of
medical services that has an uncollected debt, a provider
that has been or is subject to a payment suspension under a
federal health care program, or a provider that has been
previously excluded from participation in the medical

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assistance program, poses a risk of fraud, waste, or abuse
to the Illinois Department.
As used in this subsection, "credible allegation" is
defined to include an allegation from any source, including,
but not limited to, fraud hotline complaints, claims data
mining, patterns identified through provider audits, civil
actions filed under the Illinois False Claims Act, and law
enforcement investigations. An allegation is considered to be
credible when it has indicia of reliability.
(B) The Illinois Department shall deny, suspend or
terminate the eligibility of any person, firm, corporation,
association, agency, institution or other legal entity to
participate as a vendor of goods or services to recipients
under the medical assistance program under Article V, or may
exclude any such person or entity from participation as such a
vendor:
(1) immediately, if such vendor is not properly
licensed, certified, or authorized;
(2) within 30 days of the date when such vendor's
professional license, certification or other authorization
has been refused renewal, restricted, revoked, suspended,
or otherwise terminated; or
(3) if such vendor has been convicted of a violation
of this Code, as provided in Article VIIIA.
(C) Upon termination, suspension, or exclusion of a vendor
of goods or services from participation in the medical

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assistance program authorized by this Article, a person with
management responsibility for such vendor during the time of
any conduct which served as the basis for that vendor's
termination, suspension, or exclusion is barred from
participation in the medical assistance program.
Upon termination, suspension, or exclusion of a corporate
vendor, the officers and persons owning, directly or
indirectly, 5% or more of the shares of stock or other
evidences of ownership in the vendor during the time of any
conduct which served as the basis for that vendor's
termination, suspension, or exclusion are barred from
participation in the medical assistance program. A person who
owns, directly or indirectly, 5% or more of the shares of stock
or other evidences of ownership in a terminated, suspended, or
excluded vendor may not transfer his or her ownership interest
in that vendor to his or her spouse, child, brother, sister,
parent, grandparent, grandchild, uncle, aunt, niece, nephew,
cousin, or relative by marriage.
Upon termination, suspension, or exclusion of a sole
proprietorship or partnership, the owner or partners during
the time of any conduct which served as the basis for that
vendor's termination, suspension, or exclusion are barred from
participation in the medical assistance program. The owner of
a terminated, suspended, or excluded vendor that is a sole
proprietorship, and a partner in a terminated, suspended, or
excluded vendor that is a partnership, may not transfer his or

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her ownership or partnership interest in that vendor to his or
her spouse, child, brother, sister, parent, grandparent,
grandchild, uncle, aunt, niece, nephew, cousin, or relative by
marriage.
A person who owns, directly or indirectly, 5% or more of
the shares of stock or other evidences of ownership in a
corporate or limited liability company vendor who owes a debt
to the Department, if that vendor has not made payment
arrangements acceptable to the Department, shall not transfer
his or her ownership interest in that vendor, or vendor assets
of any kind, to his or her spouse, child, brother, sister,
parent, grandparent, grandchild, uncle, aunt, niece, nephew,
cousin, or relative by marriage.
Rules adopted by the Illinois Department to implement
these provisions shall specifically include a definition of
the term "management responsibility" as used in this Section.
Such definition shall include, but not be limited to, typical
job titles, and duties and descriptions which will be
considered as within the definition of individuals with
management responsibility for a provider.
A vendor or a prior vendor who has been terminated,
excluded, or suspended from the medical assistance program, or
from another state or federal medical assistance or health
care program, and any individual currently or previously
barred from the medical assistance program, or from another
state or federal medical assistance or health care program, as

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a result of being an officer or a person owning, directly or
indirectly, 5% or more of the shares of stock or other
evidences of ownership in a corporate or limited liability
company vendor during the time of any conduct which served as
the basis for that vendor's termination, suspension, or
exclusion, may be required to post a surety bond as part of a
condition of enrollment or participation in the medical
assistance program. The Illinois Department shall establish,
by rule, the criteria and requirements for determining when a
surety bond must be posted and the value of the bond.
A vendor or a prior vendor who has a debt owed to the
Illinois Department and any individual currently or previously
barred from the medical assistance program, or from another
state or federal medical assistance or health care program, as
a result of being an officer or a person owning, directly or
indirectly, 5% or more of the shares of stock or other
evidences of ownership in that corporate or limited liability
company vendor during the time of any conduct which served as
the basis for the debt, may be required to post a surety bond
as part of a condition of enrollment or participation in the
medical assistance program. The Illinois Department shall
establish, by rule, the criteria and requirements for
determining when a surety bond must be posted and the value of
the bond.
(D) If a vendor has been suspended from the medical
assistance program under Article V of the Code, the Director

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may require that such vendor correct any deficiencies which
served as the basis for the suspension. The Director shall
specify in the suspension order a specific period of time,
which shall not exceed one year from the date of the order,
during which a suspended vendor shall not be eligible to
participate. At the conclusion of the period of suspension the
Director shall reinstate such vendor, unless he finds that
such vendor has not corrected deficiencies upon which the
suspension was based.
If a vendor has been terminated, suspended, or excluded
from the medical assistance program under Article V, such
vendor shall be barred from participation for at least one
year, except that if a vendor has been terminated, suspended,
or excluded based on a conviction of a violation of Article
VIIIA or a conviction of a felony based on fraud or a willful
misrepresentation related to (i) the medical assistance
program under Article V, (ii) a federal or another state's
medical assistance or health care program, or (iii) the
provision of health care services, then the vendor shall be
barred from participation for 5 years or for the length of the
vendor's sentence for that conviction, whichever is longer. At
the end of one year a vendor who has been terminated,
suspended, or excluded may apply for reinstatement to the
program. Upon proper application to be reinstated such vendor
may be deemed eligible by the Director providing that such
vendor meets the requirements for eligibility under this Code.

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If such vendor is deemed not eligible for reinstatement, he
shall be barred from again applying for reinstatement for one
year from the date his application for reinstatement is
denied.
A vendor whose termination, suspension, or exclusion from
participation in the Illinois medical assistance program under
Article V was based solely on an action by a governmental
entity other than the Illinois Department may, upon
reinstatement by that governmental entity or upon reversal of
the termination, suspension, or exclusion, apply for
rescission of the termination, suspension, or exclusion from
participation in the Illinois medical assistance program. Upon
proper application for rescission, the vendor may be deemed
eligible by the Director if the vendor meets the requirements
for eligibility under this Code.
If a vendor has been terminated, suspended, or excluded
and reinstated to the medical assistance program under Article
V and the vendor is terminated, suspended, or excluded a
second or subsequent time from the medical assistance program,
the vendor shall be barred from participation for at least 2
years, except that if a vendor has been terminated, suspended,
or excluded a second time based on a conviction of a violation
of Article VIIIA or a conviction of a felony based on fraud or
a willful misrepresentation related to (i) the medical
assistance program under Article V, (ii) a federal or another
state's medical assistance or health care program, or (iii)

10400SB3365ham001 - 447 - LRB104 18483 KTG 38682 a
the provision of health care services, then the vendor shall
be barred from participation for life. At the end of 2 years, a
vendor who has been terminated, suspended, or excluded may
apply for reinstatement to the program. Upon application to be
reinstated, the vendor may be deemed eligible if the vendor
meets the requirements for eligibility under this Code. If the
vendor is deemed not eligible for reinstatement, the vendor
shall be barred from again applying for reinstatement for 2
years from the date the vendor's application for reinstatement
is denied.
(E) The Illinois Department may recover money improperly
or erroneously paid, or overpayments, either by setoff,
crediting against future billings or by requiring direct
repayment to the Illinois Department. The Illinois Department
may suspend or deny payment, in whole or in part, if such
payment would be improper or erroneous or would otherwise
result in overpayment.
(1) Payments may be suspended, denied, or recovered
from a vendor or alternate payee: (i) for services
rendered in violation of the Illinois Department's
provider notices, statutes, rules, and regulations; (ii)
for services rendered in violation of the terms and
conditions prescribed by the Illinois Department in its
vendor agreement; (iii) for any vendor who fails to grant
the Office of Inspector General timely access to full and
complete records, including, but not limited to, records

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relating to recipients under the medical assistance
program for the most recent 6 years, in accordance with
Section 140.28 of Title 89 of the Illinois Administrative
Code, and other information for the purpose of audits,
investigations, or other program integrity functions,
after reasonable written request by the Inspector General;
this subsection (E) does not require vendors to make
available the medical records of patients for whom
services are not reimbursed under this Code or to provide
access to medical records more than 6 years old; (iv) when
the vendor has knowingly made, or caused to be made, any
false statement or representation of a material fact in
connection with the administration of the medical
assistance program; or (v) when the vendor previously
rendered services while terminated, suspended, or excluded
from participation in the medical assistance program or
while terminated or excluded from participation in another
state or federal medical assistance or health care
program.
(2) Notwithstanding any other provision of law, if a
vendor has the same taxpayer identification number
(assigned under Section 6109 of the Internal Revenue Code
of 1986) as is assigned to a vendor with past-due
financial obligations to the Illinois Department, the
Illinois Department may make any necessary adjustments to
payments to that vendor in order to satisfy any past-due

10400SB3365ham001 - 449 - LRB104 18483 KTG 38682 a
obligations, regardless of whether the vendor is assigned
a different billing number under the medical assistance
program.
(E-5) Civil monetary penalties.
(1) As used in this subsection (E-5):
(a) "Knowingly" means that a person, with respect
to information: (i) has actual knowledge of the
information; (ii) acts in deliberate ignorance of the
truth or falsity of the information; or (iii) acts in
reckless disregard of the truth or falsity of the
information. No proof of specific intent to defraud is
required.
(b) "Overpayment" means any funds that a person
receives or retains from the medical assistance
program to which the person, after applicable
reconciliation, is not entitled under this Code.
(c) "Remuneration" means the offer or transfer of
items or services for free or for other than fair
market value by a person; however, remuneration does
not include items or services of a nominal value of no
more than $10 per item or service, or $50 in the
aggregate on an annual basis, or any other offer or
transfer of items or services as determined by the
Department.
(d) "Should know" means that a person, with
respect to information: (i) acts in deliberate

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ignorance of the truth or falsity of the information;
or (ii) acts in reckless disregard of the truth or
falsity of the information. No proof of specific
intent to defraud is required.
(2) Any person (including a vendor, provider,
organization, agency, or other entity, or an alternate
payee thereof, but excluding a recipient) who:
(a) knowingly presents or causes to be presented
to an officer, employee, or agent of the State, a claim
that the Department determines:
(i) is for a medical or other item or service
that the person knows or should know was not
provided as claimed, including any person who
engages in a pattern or practice of presenting or
causing to be presented a claim for an item or
service that is based on a code that the person
knows or should know will result in a greater
payment to the person than the code the person
knows or should know is applicable to the item or
service actually provided;
(ii) is for a medical or other item or service
and the person knows or should know that the claim
is false or fraudulent;
(iii) is presented for a vendor physician's
service, or an item or service incident to a
vendor physician's service, by a person who knows

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or should know that the individual who furnished,
or supervised the furnishing of, the service:
(AA) was not licensed as a physician;
(BB) was licensed as a physician but such
license had been obtained through a
misrepresentation of material fact (including
cheating on an examination required for
licensing); or
(CC) represented to the patient at the
time the service was furnished that the
physician was certified in a medical specialty
by a medical specialty board, when the
individual was not so certified;
(iv) is for a medical or other item or service
furnished during a period in which the person was
excluded from the medical assistance program or a
federal or state health care program under which
the claim was made pursuant to applicable law; or
(v) is for a pattern of medical or other items
or services that a person knows or should know are
not medically necessary;
(b) knowingly presents or causes to be presented
to any person a request for payment which is in
violation of the conditions for receipt of vendor
payments under the medical assistance program under
Section 11-13 of this Code;

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(c) knowingly gives or causes to be given to any
person, with respect to medical assistance program
coverage of inpatient hospital services, information
that he or she knows or should know is false or
misleading, and that could reasonably be expected to
influence the decision when to discharge such person
or other individual from the hospital;
(d) in the case of a person who is not an
organization, agency, or other entity, is excluded
from participating in the medical assistance program
or a federal or state health care program and who, at
the time of a violation of this subsection (E-5):
(i) retains a direct or indirect ownership or
control interest in an entity that is
participating in the medical assistance program or
a federal or state health care program, and who
knows or should know of the action constituting
the basis for the exclusion; or
(ii) is an officer or managing employee of
such an entity;
(e) offers or transfers remuneration to any
individual eligible for benefits under the medical
assistance program that such person knows or should
know is likely to influence such individual to order
or receive from a particular vendor, provider,
practitioner, or supplier any item or service for

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which payment may be made, in whole or in part, under
the medical assistance program;
(f) arranges or contracts (by employment or
otherwise) with an individual or entity that the
person knows or should know is excluded from
participation in the medical assistance program or a
federal or state health care program, for the
provision of items or services for which payment may
be made under such a program;
(g) commits an act described in subsection (b) or
(c) of Section 8A-3;
(h) knowingly makes, uses, or causes to be made or
used, a false record or statement material to a false
or fraudulent claim for payment for items and services
furnished under the medical assistance program;
(i) fails to grant timely access, upon reasonable
request (as defined by the Department by rule), to the
Inspector General, for the purpose of audits,
investigations, evaluations, or other statutory
functions of the Inspector General of the Department;
(j) orders or prescribes a medical or other item
or service during a period in which the person was
excluded from the medical assistance program or a
federal or state health care program, in the case
where the person knows or should know that a claim for
such medical or other item or service will be made

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under such a program;
(k) knowingly makes or causes to be made any false
statement, omission, or misrepresentation of a
material fact in any application, bid, or contract to
participate or enroll as a vendor or provider of
services or a supplier under the medical assistance
program;
(l) knows of an overpayment and does not report
and return the overpayment to the Department in
accordance with paragraph (6);
shall be subject, in addition to any other penalties that
may be prescribed by law, to a civil money penalty of not
more than $10,000 for each item or service (or, in cases
under subparagraph (c), $15,000 for each individual with
respect to whom false or misleading information was given;
in cases under subparagraph (d), $10,000 for each day the
prohibited relationship occurs; in cases under
subparagraph (g), $50,000 for each such act; in cases
under subparagraph (h), $50,000 for each false record or
statement; in cases under subparagraph (i), $15,000 for
each day of the failure described in such subparagraph; or
in cases under subparagraph (k), $50,000 for each false
statement, omission, or misrepresentation of a material
fact). In addition, such a person shall be subject to an
assessment of not more than 3 times the amount claimed for
each such item or service in lieu of damages sustained by

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the State because of such claim (or, in cases under
subparagraph (g), damages of not more than 3 times the
total amount of remuneration offered, paid, solicited, or
received, without regard to whether a portion of such
remuneration was offered, paid, solicited, or received for
a lawful purpose; or in cases under subparagraph (k), an
assessment of not more than 3 times the total amount
claimed for each item or service for which payment was
made based upon the application, bid, or contract
containing the false statement, omission, or
misrepresentation of a material fact).
(3) In addition, the Director or his or her designee
may make a determination in the same proceeding to
exclude, terminate, suspend, or bar the person from
participation in the medical assistance program.
(4) The Illinois Department may seek the civil
monetary penalties and exclusion, termination, suspension,
or barment identified in this subsection (E-5). Prior to
the imposition of any penalties or sanctions, the affected
person shall be afforded an opportunity for a hearing
after reasonable notice. The Department shall establish
hearing procedures by rule.
(5) Any final order, decision, or other determination
made, issued, or executed by the Director under the
provisions of this subsection (E-5), whereby a person is
aggrieved, shall be subject to review in accordance with

10400SB3365ham001 - 456 - LRB104 18483 KTG 38682 a
the provisions of the Administrative Review Law, and the
rules adopted pursuant thereto, which shall apply to and
govern all proceedings for the judicial review of final
administrative decisions of the Director.
(6)(a) If a person has received an overpayment, the
person shall:
(i) report and return the overpayment to the
Department at the correct address; and
(ii) notify the Department in writing of the
reason for the overpayment.
(b) An overpayment must be reported and returned under
subparagraph (a) by the later of:
(i) the date which is 60 days after the date on
which the overpayment was identified; or
(ii) the date any corresponding cost report is
due, if applicable.
(E-10) A vendor who disputes an overpayment identified as
part of a Department audit shall utilize the Department's
self-referral disclosure protocol as set forth under this Code
to identify, investigate, and return to the Department any
undisputed audit overpayment amount. Unless the disputed
overpayment amount is subject to a fraud payment suspension,
or involves a termination sanction, the Department shall defer
the recovery of the disputed overpayment amount up to one year
after the date of the Department's final audit determination,
or earlier, or as required by State or federal law. If the

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administrative hearing extends beyond one year, and such delay
was not caused by the request of the vendor, then the
Department shall not recover the disputed overpayment amount
until the date of the final administrative decision. If a
final administrative decision establishes that the disputed
overpayment amount is owed to the Department, then the amount
shall be immediately due to the Department. The Department
shall be entitled to recover interest from the vendor on the
overpayment amount from the date of the overpayment through
the date the vendor returns the overpayment to the Department
at a rate not to exceed the Wall Street Journal Prime Rate, as
published from time to time, but not to exceed 5%. Any interest
billed by the Department shall be due immediately upon receipt
of the Department's billing statement.
(F) The Illinois Department may withhold payments to any
vendor or alternate payee prior to or during the pendency of
any audit or proceeding under this Section, and through the
pendency of any administrative appeal or administrative review
by any court proceeding. The Illinois Department shall state
by rule with as much specificity as practicable the conditions
under which payments will not be withheld under this Section.
Payments may be denied for bills submitted with service dates
occurring during the pendency of a proceeding, after a final
decision has been rendered, or after the conclusion of any
administrative appeal, where the final administrative decision
is to terminate, exclude, or suspend eligibility to

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participate in the medical assistance program. The Illinois
Department shall state by rule with as much specificity as
practicable the conditions under which payments will not be
denied for such bills. The Illinois Department shall state by
rule a process and criteria by which a vendor or alternate
payee may request full or partial release of payments withheld
under this subsection. The Department must complete a
proceeding under this Section in a timely manner.
Notwithstanding recovery allowed under subsection (E) or
this subsection (F), the Illinois Department may withhold
payments to any vendor or alternate payee who is not properly
licensed, certified, or in compliance with State or federal
agency regulations. Payments may be denied for bills submitted
with service dates occurring during the period of time that a
vendor is not properly licensed, certified, or in compliance
with State or federal regulations. Facilities licensed under
the Nursing Home Care Act shall have payments denied or
withheld pursuant to subsection (I) of this Section.
(F-5) The Illinois Department may temporarily withhold
payments to a vendor or alternate payee if any of the following
individuals have been indicted or otherwise charged under a
law of the United States or this or any other state with an
offense that is based on alleged fraud or willful
misrepresentation on the part of the individual related to (i)
the medical assistance program under Article V of this Code,
(ii) a federal or another state's medical assistance or health

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care program, or (iii) the provision of health care services:
(1) If the vendor or alternate payee is a corporation:
an officer of the corporation or an individual who owns,
either directly or indirectly, 5% or more of the shares of
stock or other evidence of ownership of the corporation.
(2) If the vendor is a sole proprietorship: the owner
of the sole proprietorship.
(3) If the vendor or alternate payee is a partnership:
a partner in the partnership.
(4) If the vendor or alternate payee is any other
business entity authorized by law to transact business in
this State: an officer of the entity or an individual who
owns, either directly or indirectly, 5% or more of the
evidences of ownership of the entity.
If the Illinois Department withholds payments to a vendor
or alternate payee under this subsection, the Department shall
not release those payments to the vendor or alternate payee
while any criminal proceeding related to the indictment or
charge is pending unless the Department determines that there
is good cause to release the payments before completion of the
proceeding. If the indictment or charge results in the
individual's conviction, the Illinois Department shall retain
all withheld payments, which shall be considered forfeited to
the Department. If the indictment or charge does not result in
the individual's conviction, the Illinois Department shall
release to the vendor or alternate payee all withheld

10400SB3365ham001 - 460 - LRB104 18483 KTG 38682 a
payments.
(F-10) If the Illinois Department establishes that the
vendor or alternate payee owes a debt to the Illinois
Department, and the vendor or alternate payee subsequently
fails to pay or make satisfactory payment arrangements with
the Illinois Department for the debt owed, the Illinois
Department may seek all remedies available under the law of
this State to recover the debt, including, but not limited to,
wage garnishment or the filing of claims or liens against the
vendor or alternate payee.
(F-15) Enforcement of judgment.
(1) Any fine, recovery amount, other sanction, or
costs imposed, or part of any fine, recovery amount, other
sanction, or cost imposed, remaining unpaid after the
exhaustion of or the failure to exhaust judicial review
procedures under the Illinois Administrative Review Law is
a debt due and owing the State and may be collected using
all remedies available under the law.
(2) After expiration of the period in which judicial
review under the Illinois Administrative Review Law may be
sought for a final administrative decision, unless stayed
by a court of competent jurisdiction, the findings,
decision, and order of the Director may be enforced in the
same manner as a judgment entered by a court of competent
jurisdiction.
(3) In any case in which any person or entity has

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failed to comply with a judgment ordering or imposing any
fine or other sanction, any expenses incurred by the
Illinois Department to enforce the judgment, including,
but not limited to, attorney's fees, court costs, and
costs related to property demolition or foreclosure, after
they are fixed by a court of competent jurisdiction or the
Director, shall be a debt due and owing the State and may
be collected in accordance with applicable law. Prior to
any expenses being fixed by a final administrative
decision pursuant to this subsection (F-15), the Illinois
Department shall provide notice to the individual or
entity that states that the individual or entity shall
appear at a hearing before the administrative hearing
officer to determine whether the individual or entity has
failed to comply with the judgment. The notice shall set
the date for such a hearing, which shall not be less than 7
days from the date that notice is served. If notice is
served by mail, the 7-day period shall begin to run on the
date that the notice was deposited in the mail.
(4) Upon being recorded in the manner required by
Article XII of the Code of Civil Procedure or by the
Uniform Commercial Code, a lien shall be imposed on the
real estate or personal estate, or both, of the individual
or entity in the amount of any debt due and owing the State
under this Section. The lien may be enforced in the same
manner as a judgment of a court of competent jurisdiction.

10400SB3365ham001 - 462 - LRB104 18483 KTG 38682 a
A lien shall attach to all property and assets of such
person, firm, corporation, association, agency,
institution, or other legal entity until the judgment is
satisfied.
(5) The Director may set aside any judgment entered by
default and set a new hearing date upon a petition filed at
any time (i) if the petitioner's failure to appear at the
hearing was for good cause, or (ii) if the petitioner
established that the Department did not provide proper
service of process. If any judgment is set aside pursuant
to this paragraph (5), the hearing officer shall have
authority to enter an order extinguishing any lien which
has been recorded for any debt due and owing the Illinois
Department as a result of the vacated default judgment.
(G) The provisions of the Administrative Review Law, as
now or hereafter amended, and the rules adopted pursuant
thereto, shall apply to and govern all proceedings for the
judicial review of final administrative decisions of the
Illinois Department under this Section. The term
"administrative decision" is defined as in Section 3-101 of
the Code of Civil Procedure.
(G-5) Vendors who pose a risk of fraud, waste, abuse, or
harm.
(1) Notwithstanding any other provision in this
Section, the Department may terminate, suspend, or exclude
vendors who pose a risk of fraud, waste, abuse, or harm

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from participation in the medical assistance program prior
to an evidentiary hearing but after reasonable notice and
opportunity to respond as established by the Department by
rule.
(2) Vendors who pose a risk of fraud, waste, abuse, or
harm shall submit to a fingerprint-based criminal
background check on current and future information
available in the State system and current information
available through the Federal Bureau of Investigation's
system by submitting all necessary fees and information in
the form and manner prescribed by the Illinois State
Police. The following individuals shall be subject to the
check:
(A) In the case of a vendor that is a corporation,
every shareholder who owns, directly or indirectly, 5%
or more of the outstanding shares of the corporation.
(B) In the case of a vendor that is a partnership,
every partner.
(C) In the case of a vendor that is a sole
proprietorship, the sole proprietor.
(D) Each officer or manager of the vendor.
Each such vendor shall be responsible for payment of
the cost of the criminal background check.
(3) Vendors who pose a risk of fraud, waste, abuse, or
harm may be required to post a surety bond. The Department
shall establish, by rule, the criteria and requirements

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for determining when a surety bond must be posted and the
value of the bond.
(4) The Department, or its agents, may refuse to
accept requests for authorization from specific vendors
who pose a risk of fraud, waste, abuse, or harm, including
prior-approval and post-approval requests, if:
(A) the Department has initiated a notice of
termination, suspension, or exclusion of the vendor
from participation in the medical assistance program;
or
(B) the Department has issued notification of its
withholding of payments pursuant to subsection (F-5)
of this Section; or
(C) the Department has issued a notification of
its withholding of payments due to reliable evidence
of fraud or willful misrepresentation pending
investigation.
(5) As used in this subsection, the following terms
are defined as follows:
(A) "Fraud" means an intentional deception or
misrepresentation made by a person with the knowledge
that the deception could result in some unauthorized
benefit to himself or herself or some other person. It
includes any act that constitutes fraud under
applicable federal or State law.
(B) "Abuse" means provider practices that are

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inconsistent with sound fiscal, business, or medical
practices and that result in an unnecessary cost to
the medical assistance program or in reimbursement for
services that are not medically necessary or that fail
to meet professionally recognized standards for health
care. It also includes recipient practices that result
in unnecessary cost to the medical assistance program.
Abuse does not include diagnostic or therapeutic
measures conducted primarily as a safeguard against
possible vendor liability.
(C) "Waste" means the unintentional misuse of
medical assistance resources, resulting in unnecessary
cost to the medical assistance program. Waste does not
include diagnostic or therapeutic measures conducted
primarily as a safeguard against possible vendor
liability.
(D) "Harm" means physical, mental, or monetary
damage to recipients or to the medical assistance
program.
(G-6) The Illinois Department, upon making a determination
based upon information in the possession of the Illinois
Department that continuation of participation in the medical
assistance program by a vendor would constitute an immediate
danger to the public, may immediately suspend such vendor's
participation in the medical assistance program without a
hearing. In instances in which the Illinois Department

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immediately suspends the medical assistance program
participation of a vendor under this Section, a hearing upon
the vendor's participation must be convened by the Illinois
Department within 15 days after such suspension and completed
without appreciable delay. Such hearing shall be held to
determine whether to recommend to the Director that the
vendor's medical assistance program participation be denied,
terminated, suspended, placed on provisional status, or
reinstated. In the hearing, any evidence relevant to the
vendor constituting an immediate danger to the public may be
introduced against such vendor; provided, however, that the
vendor, or his or her counsel, shall have the opportunity to
discredit, impeach, and submit evidence rebutting such
evidence.
(H) Nothing contained in this Code shall in any way limit
or otherwise impair the authority or power of any State agency
responsible for licensing of vendors.
(I) Based on a finding of noncompliance on the part of a
nursing home with any requirement for certification under
Title XVIII or XIX of the Social Security Act (42 U.S.C. Sec.
1395 et seq. or 42 U.S.C. Sec. 1396 et seq.), the Illinois
Department may impose one or more of the following remedies
after notice to the facility:
(1) Termination of the provider agreement.
(2) Temporary management.
(3) Denial of payment for new admissions.

10400SB3365ham001 - 467 - LRB104 18483 KTG 38682 a
(4) Civil money penalties.
(5) Closure of the facility in emergency situations or
transfer of residents, or both.
(6) State monitoring.
(7) Denial of all payments when the U.S. Department of
Health and Human Services has imposed this sanction.
The Illinois Department shall by rule establish criteria
governing continued payments to a nursing facility subsequent
to termination of the facility's provider agreement if, in the
sole discretion of the Illinois Department, circumstances
affecting the health, safety, and welfare of the facility's
residents require those continued payments. The Illinois
Department may condition those continued payments on the
appointment of temporary management, sale of the facility to
new owners or operators, or other arrangements that the
Illinois Department determines best serve the needs of the
facility's residents.
Except in the case of a facility that has a right to a
hearing on the finding of noncompliance before an agency of
the federal government, a facility may request a hearing
before a State agency on any finding of noncompliance within
60 days after the notice of the intent to impose a remedy.
Except in the case of civil money penalties, a request for a
hearing shall not delay imposition of the penalty. The choice
of remedies is not appealable at a hearing. The level of
noncompliance may be challenged only in the case of a civil

10400SB3365ham001 - 468 - LRB104 18483 KTG 38682 a
money penalty. The Illinois Department shall provide by rule
for the State agency that will conduct the evidentiary
hearings.
The Illinois Department may collect interest on unpaid
civil money penalties.
The Illinois Department may adopt all rules necessary to
implement this subsection (I).
(J) The Illinois Department, by rule, may permit
individual practitioners to designate that Department payments
that may be due the practitioner be made to an alternate payee
or alternate payees.
(a) Such alternate payee or alternate payees shall be
required to register as an alternate payee in the Medical
Assistance Program with the Illinois Department.
(b) If a practitioner designates an alternate payee,
the alternate payee and practitioner shall be jointly and
severally liable to the Department for payments made to
the alternate payee. Pursuant to subsection (E) of this
Section, any Department action to suspend or deny payment
or recover money or overpayments from an alternate payee
shall be subject to an administrative hearing.
(c) Registration as an alternate payee or alternate
payees in the Illinois Medical Assistance Program shall be
conditional. At any time, the Illinois Department may deny
or cancel any alternate payee's registration in the
Illinois Medical Assistance Program without cause. Any

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such denial or cancellation is not subject to an
administrative hearing.
(d) The Illinois Department may seek a revocation of
any alternate payee, and all owners, officers, and
individuals with management responsibility for such
alternate payee shall be permanently prohibited from
participating as an owner, an officer, or an individual
with management responsibility with an alternate payee in
the Illinois Medical Assistance Program, if after
reasonable notice and opportunity for a hearing the
Illinois Department finds that:
(1) the alternate payee is not complying with the
Department's policy or rules and regulations, or with
the terms and conditions prescribed by the Illinois
Department in its alternate payee registration
agreement; or
(2) the alternate payee has failed to keep or make
available for inspection, audit, or copying, after
receiving a written request from the Illinois
Department, such records regarding payments claimed as
an alternate payee; or
(3) the alternate payee has failed to furnish any
information requested by the Illinois Department
regarding payments claimed as an alternate payee; or
(4) the alternate payee has knowingly made, or
caused to be made, any false statement or

10400SB3365ham001 - 470 - LRB104 18483 KTG 38682 a
representation of a material fact in connection with
the administration of the Illinois Medical Assistance
Program; or
(5) the alternate payee, a person with management
responsibility for an alternate payee, an officer or
person owning, either directly or indirectly, 5% or
more of the shares of stock or other evidences of
ownership in a corporate alternate payee, or a partner
in a partnership which is an alternate payee:
(a) was previously terminated, suspended, or
excluded from participation as a vendor in the
Illinois Medical Assistance Program, or was
previously revoked as an alternate payee in the
Illinois Medical Assistance Program, or was
terminated, suspended, or excluded from
participation as a vendor in a medical assistance
program in another state that is of the same kind
as the program of medical assistance provided
under Article V of this Code; or
(b) was a person with management
responsibility for a vendor previously terminated,
suspended, or excluded from participation as a
vendor in the Illinois Medical Assistance Program,
or was previously revoked as an alternate payee in
the Illinois Medical Assistance Program, or was
terminated, suspended, or excluded from

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participation as a vendor in a medical assistance
program in another state that is of the same kind
as the program of medical assistance provided
under Article V of this Code, during the time of
conduct which was the basis for that vendor's
termination, suspension, or exclusion or alternate
payee's revocation; or
(c) was an officer, or person owning, either
directly or indirectly, 5% or more of the shares
of stock or other evidences of ownership in a
corporate vendor previously terminated, suspended,
or excluded from participation as a vendor in the
Illinois Medical Assistance Program, or was
previously revoked as an alternate payee in the
Illinois Medical Assistance Program, or was
terminated, suspended, or excluded from
participation as a vendor in a medical assistance
program in another state that is of the same kind
as the program of medical assistance provided
under Article V of this Code, during the time of
conduct which was the basis for that vendor's
termination, suspension, or exclusion; or
(d) was an owner of a sole proprietorship or
partner in a partnership previously terminated,
suspended, or excluded from participation as a
vendor in the Illinois Medical Assistance Program,

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or was previously revoked as an alternate payee in
the Illinois Medical Assistance Program, or was
terminated, suspended, or excluded from
participation as a vendor in a medical assistance
program in another state that is of the same kind
as the program of medical assistance provided
under Article V of this Code, during the time of
conduct which was the basis for that vendor's
termination, suspension, or exclusion or alternate
payee's revocation; or
(6) the alternate payee, a person with management
responsibility for an alternate payee, an officer or
person owning, either directly or indirectly, 5% or
more of the shares of stock or other evidences of
ownership in a corporate alternate payee, or a partner
in a partnership which is an alternate payee:
(a) has engaged in conduct prohibited by
applicable federal or State law or regulation
relating to the Illinois Medical Assistance
Program; or
(b) was a person with management
responsibility for a vendor or alternate payee at
the time that the vendor or alternate payee
engaged in practices prohibited by applicable
federal or State law or regulation relating to the
Illinois Medical Assistance Program; or

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(c) was an officer, or person owning, either
directly or indirectly, 5% or more of the shares
of stock or other evidences of ownership in a
vendor or alternate payee at the time such vendor
or alternate payee engaged in practices prohibited
by applicable federal or State law or regulation
relating to the Illinois Medical Assistance
Program; or
(d) was an owner of a sole proprietorship or
partner in a partnership which was a vendor or
alternate payee at the time such vendor or
alternate payee engaged in practices prohibited by
applicable federal or State law or regulation
relating to the Illinois Medical Assistance
Program; or
(7) the direct or indirect ownership of the vendor
or alternate payee (including the ownership of a
vendor or alternate payee that is a partner's interest
in a vendor or alternate payee, or ownership of 5% or
more of the shares of stock or other evidences of
ownership in a corporate vendor or alternate payee)
has been transferred by an individual who is
terminated, suspended, or excluded or barred from
participating as a vendor or is prohibited or revoked
as an alternate payee to the individual's spouse,
child, brother, sister, parent, grandparent,

10400SB3365ham001 - 474 - LRB104 18483 KTG 38682 a
grandchild, uncle, aunt, niece, nephew, cousin, or
relative by marriage.
(K) The Illinois Department of Healthcare and Family
Services may withhold payments, in whole or in part, to a
provider or alternate payee where there is credible evidence,
received from State or federal law enforcement or federal
oversight agencies or from the results of a preliminary
Department audit, that the circumstances giving rise to the
need for a withholding of payments may involve fraud or
willful misrepresentation under the Illinois Medical
Assistance program. The Department shall by rule define what
constitutes "credible" evidence for purposes of this
subsection. The Department may withhold payments without first
notifying the provider or alternate payee of its intention to
withhold such payments. A provider or alternate payee may
request a reconsideration of payment withholding, and the
Department must grant such a request. The Department shall
state by rule a process and criteria by which a provider or
alternate payee may request full or partial release of
payments withheld under this subsection. This request may be
made at any time after the Department first withholds such
payments.
(a) The Illinois Department must send notice of its
withholding of program payments within 5 days of taking
such action. The notice must set forth the general
allegations as to the nature of the withholding action,

10400SB3365ham001 - 475 - LRB104 18483 KTG 38682 a
but need not disclose any specific information concerning
its ongoing investigation. The notice must do all of the
following:
(1) State that payments are being withheld in
accordance with this subsection.
(2) State that the withholding is for a temporary
period, as stated in paragraph (b) of this subsection,
and cite the circumstances under which withholding
will be terminated.
(3) Specify, when appropriate, which type or types
of Medicaid claims withholding is effective.
(4) Inform the provider or alternate payee of the
right to submit written evidence for reconsideration
of the withholding by the Illinois Department.
(5) Inform the provider or alternate payee that a
written request may be made to the Illinois Department
for full or partial release of withheld payments and
that such requests may be made at any time after the
Department first withholds such payments.
(b) All withholding-of-payment actions under this
subsection shall be temporary and shall not continue after
any of the following:
(1) The Illinois Department or the prosecuting
authorities determine that there is insufficient
evidence of fraud or willful misrepresentation by the
provider or alternate payee.

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(2) Legal proceedings related to the provider's or
alternate payee's alleged fraud, willful
misrepresentation, violations of this Act, or
violations of the Illinois Department's administrative
rules are completed.
(3) The withholding of payments for a period of 3
years.
(c) The Illinois Department may adopt all rules
necessary to implement this subsection (K).
(K-5) The Illinois Department may withhold payments, in
whole or in part, to a provider or alternate payee upon
initiation of an audit, quality of care review, investigation
when there is a credible allegation of fraud, or the provider
or alternate payee demonstrating a clear failure to cooperate
with the Illinois Department such that the circumstances give
rise to the need for a withholding of payments. As used in this
subsection, "credible allegation" is defined to include an
allegation from any source, including, but not limited to,
fraud hotline complaints, claims data mining, patterns
identified through provider audits, civil actions filed under
the Illinois False Claims Act, and law enforcement
investigations. An allegation is considered to be credible
when it has indicia of reliability. The Illinois Department
may withhold payments without first notifying the provider or
alternate payee of its intention to withhold such payments. A
provider or alternate payee may request a hearing or a

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reconsideration of payment withholding, and the Illinois
Department must grant such a request. The Illinois Department
shall state by rule a process and criteria by which a provider
or alternate payee may request a hearing or a reconsideration
for the full or partial release of payments withheld under
this subsection. This request may be made at any time after the
Illinois Department first withholds such payments.
(a) The Illinois Department must send notice of its
withholding of program payments within 5 days of taking
such action. The notice must set forth the general
allegations as to the nature of the withholding action but
need not disclose any specific information concerning its
ongoing investigation. The notice must do all of the
following:
(1) State that payments are being withheld in
accordance with this subsection.
(2) State that the withholding is for a temporary
period, as stated in paragraph (b) of this subsection,
and cite the circumstances under which withholding
will be terminated.
(3) Specify, when appropriate, which type or types
of claims are withheld.
(4) Inform the provider or alternate payee of the
right to request a hearing or a reconsideration of the
withholding by the Illinois Department, including the
ability to submit written evidence.

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(5) Inform the provider or alternate payee that a
written request may be made to the Illinois Department
for a hearing or a reconsideration for the full or
partial release of withheld payments and that such
requests may be made at any time after the Illinois
Department first withholds such payments.
(b) All withholding of payment actions under this
subsection shall be temporary and shall not continue after
any of the following:
(1) The Illinois Department determines that there
is insufficient evidence of fraud, or the provider or
alternate payee demonstrates clear cooperation with
the Illinois Department, as determined by the Illinois
Department, such that the circumstances do not give
rise to the need for withholding of payments; or
(2) The withholding of payments has lasted for a
period in excess of 3 years.
(c) The Illinois Department may adopt all rules
necessary to implement this subsection (K-5).
(L) The Illinois Department shall establish a protocol to
enable health care providers to disclose an actual or
potential violation of this Section pursuant to a
self-referral disclosure protocol, referred to in this
subsection as "the protocol". The protocol shall include
direction for health care providers on a specific person,
official, or office to whom such disclosures shall be made.

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The Illinois Department shall post information on the protocol
on the Illinois Department's public website. The Illinois
Department may adopt rules necessary to implement this
subsection (L). In addition to other factors that the Illinois
Department finds appropriate, the Illinois Department may
consider a health care provider's timely use or failure to use
the protocol in considering the provider's failure to comply
with this Code.
(M) Notwithstanding any other provision of this Code, the
Illinois Department, at its discretion, may exempt an entity
licensed under the Nursing Home Care Act, the ID/DD Community
Care Act, or the MC/DD Act from the provisions of subsections
(A-15), (B), and (C) of this Section if the licensed entity is
in receivership.
(N) Enforcement of advance payment agreements. To the
extent not prohibited by federal or State law, and
notwithstanding any other provision of this Code, if a
provider fails to comply with the terms of an advance payment
agreement, the Department is authorized to collect any unpaid
advance balance through one or more of the following methods:
(1) Direct withholding of Department reimbursements.
The Department may withhold reimbursement or other amounts
otherwise payable by the Department to the provider,
including, but not limited to, fee-for-service claims
payments, supplemental payments, and any other amounts the
Department is obligated to pay the provider under the

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medical assistance program, and apply such withheld
amounts as repayment of the unpaid advance.
(2) Managed care organizations remittance. If a
provider participates in a managed care program
administered by the Department, the Department may direct
the managed care organization to remit to the Department
amounts otherwise payable by the managed care organization
to the provider, and apply such remitted amounts as
repayment of the unpaid advance.
(3) Interagency recoupment. The Department may recoup
amounts otherwise payable by any State agency to the
provider, including, but not limited to, State grants and
grant appropriations, and apply such amounts as repayment
of the unpaid advance.
(4) Other collection methods. The Department may
pursue any other collection remedy available at law.
The Department shall adopt rules establishing procedures
for collection under this subsection (N). For purposes of this
subsection (N), "provider" includes, but is not limited to, a
long-term care facility as defined under the Nursing Home Care
Act and a hospital provider as defined under Article V-A of
this Code.
(Source: P.A. 102-538, eff. 8-20-21.)
ARTICLE 260.

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Section 260-5. The Illinois Administrative Procedure Act
is amended by adding Section 5-45.73 as follows:
(5 ILCS 100/5-45.73 new)
Sec. 5-45.73. Emergency rulemaking; Nursing home staffing
ratios. To provide for the expeditious and timely
implementation of the changes made by this amendatory Act of
the 104th General Assembly to Section 3-202.05 of the Nursing
Home Care Act, emergency rules implementing the changes made
by this amendatory Act of the 104th General Assembly to
Section 3-202.05 of the Nursing Home Care Act may be adopted in
accordance with Section 5-45 by the Department of Public
Health. The adoption of emergency rules authorized by Section
5-45 and this Section is deemed to be necessary for the public
interest, safety, and welfare.
This Section is repealed one year after the effective date
of this amendatory Act of the 104th General Assembly.
Section 260-10. The Nursing Home Care Act is amended by
changing Sections 3-130 and 3-202.05 as follows:
(210 ILCS 45/3-130 new)
Sec. 3-130. Annual training for facility staff. A facility
must provide its staff with annual training based on the most
recurrent citations as specified by the Department. The annual
training requirements will be defined by the Department

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annually based on the most frequent and recurrent findings or
citations during surveys or complaint investigations. The
facility must provide proof or documentation of the annual
training performed for the recurrent violations. Failure to
provide such proof or documentation may result in
administrative fines and penalties under this Act. The
Department may adopt any rules necessary to implement this
Section.
The provisions of this Section are declarative of existing
law.
(210 ILCS 45/3-202.05)
Sec. 3-202.05. Staffing ratios effective July 1, 2010 and
thereafter.
(a) For the purpose of computing staff to resident ratios,
direct care staff shall include:
(1) registered nurses;
(2) licensed practical nurses;
(3) certified nurse assistants;
(4) psychiatric services rehabilitation aides;
(5) rehabilitation and therapy aides;
(6) psychiatric services rehabilitation coordinators;
(7) assistant directors of nursing;
(8) 50% of the Director of Nurses' time; and
(9) 30% of the Social Services Directors' time.
The Department shall, by rule, allow certain facilities

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subject to 77 Ill. Adm. Code 300.4000 and following (Subpart
S) to utilize specialized clinical staff, as defined in rules,
to count towards the staffing ratios.
Within 120 days of June 14, 2012 (the effective date of
Public Act 97-689), the Department shall promulgate rules
specific to the staffing requirements for facilities federally
defined as Institutions for Mental Disease. These rules shall
recognize the unique nature of individuals with chronic mental
health conditions, shall include minimum requirements for
specialized clinical staff, including clinical social workers,
psychiatrists, psychologists, and direct care staff set forth
in paragraphs (4) through (6) and any other specialized staff
which may be utilized and deemed necessary to count toward
staffing ratios.
Within 120 days of June 14, 2012 (the effective date of
Public Act 97-689), the Department shall promulgate rules
specific to the staffing requirements for facilities licensed
under the Specialized Mental Health Rehabilitation Act of
2013. These rules shall recognize the unique nature of
individuals with chronic mental health conditions, shall
include minimum requirements for specialized clinical staff,
including clinical social workers, psychiatrists,
psychologists, and direct care staff set forth in paragraphs
(4) through (6) and any other specialized staff which may be
utilized and deemed necessary to count toward staffing ratios.
(a-5) The Centers for Medicare and Medicaid Services'

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payroll-based journal job title codes, which correspond to the
staff used for the staffing ratios in subsection (a), are as
follows:
(1) Registered Nurse Director of Nursing, job title
code 5.
(2) Registered Nurse with Administrative Duties, job
title code 6.
(3) Registered Nurse, job title code 7.
(4) Licensed Practical/Vocational Nurse with
Administrative Duties, job title code 8.
(5) Licensed Practical/Vocational Nurse, job title
code 9.
(6) Certified Nurse Aide, job title code 10.
(7) Nurse Aide in Training, job title code 11.
(8) Medication Aide/Technician, job title code 12.
(9) Nurse Practitioner, job title code 13.
(10) Clinical Nurse Specialist, job title code 14.
(11) Occupational Therapist, job title code 18.
(12) Occupational Therapy Assistant, job title code
19.
(13) Occupational Therapy Aide, job title code 20.
(14) Physical Therapist, job title code 21.
(15) Physical Therapy Assistant, job title code 22.
(16) Physical Therapy Assistant, job title code 23.
(17) Respiratory Therapist, job title code 24.
(18) Respiratory Therapy Technician, job title code

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25.
(19) Speech/Language Pathologist, job title code 26.
(20) Qualified Activities Professional, job title code
28.
(21) Other Activities Staff, job title code 29.
(22) Qualified Social Worker, job title code 30.
(23) Other Social Worker, job title code 31.
(24) Mental Health Service Worker, job title code 34.
For all job title codes in this subsection, 100% of the
hours worked by the staff must be counted toward the
staff-to-resident ratio, except job code title 5, which is
limited to 50%, and job title codes 28, 30, and 31, which are
limited to 30%.
(b) (Blank).
(b-5) For purposes of the minimum staffing ratios in this
Section, all residents shall be classified as requiring either
skilled care or intermediate care.
As used in this subsection:
"Intermediate care" means basic nursing care and other
restorative services under periodic medical direction.
"Skilled care" means skilled nursing care, continuous
skilled nursing observations, restorative nursing, and other
services under professional direction with frequent medical
supervision.
(c) Facilities shall notify the Department within 60 days
after July 29, 2010 (the effective date of Public Act

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96-1372), in a form and manner prescribed by the Department,
of the staffing ratios in effect on July 29, 2010 (the
effective date of Public Act 96-1372) for both intermediate
and skilled care and the number of residents receiving each
level of care.
(d)(1) (Blank).
(2) (Blank).
(3) (Blank).
(4) (Blank).
(5) Effective January 1, 2014, the minimum staffing ratios
shall be increased to 3.8 hours of nursing and personal care
each day for a resident needing skilled care and 2.5 hours of
nursing and personal care each day for a resident needing
intermediate care.
(e) Ninety days after June 14, 2012 (the effective date of
Public Act 97-689), a minimum of 25% of nursing and personal
care time shall be provided by licensed nurses, with at least
10% of nursing and personal care time provided by registered
nurses. These minimum requirements shall remain in effect
until an acuity based registered nurse requirement is
promulgated by rule concurrent with the adoption of the
Resource Utilization Group classification-based payment
methodology, as provided in Section 5-5.2 of the Illinois
Public Aid Code. Registered nurses and licensed practical
nurses employed by a facility in excess of these requirements
may be used to satisfy the remaining 75% of the nursing and

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personal care time requirements. Notwithstanding this
subsection, no staffing requirement in statute in effect on
June 14, 2012 (the effective date of Public Act 97-689) shall
be reduced on account of this subsection.
(f) The Department shall propose rules that are necessary
to implement the provisions of this Section, consistent with
the changes made by this amendatory Act of the 104th General
Assembly, within 60 days after the effective date of this
amendatory Act of the 104th General Assembly. submit proposed
rules for adoption by January 1, 2020 establishing a system
for determining compliance with minimum staffing set forth in
this Section and the requirements of 77 Ill. Adm. Code
300.1230 adjusted for any waivers granted under Section
3-303.1. Compliance with minimum staffing as required by this
Section shall be determined on a quarterly basis. The
Department shall determine compliance by comparing the number
of hours provided per resident per day using the Centers for
Medicare and Medicaid Services' payroll-based journal and the
facility's daily census, broken down by intermediate and
skilled care as self-reported by the facility to the
Department on a quarterly basis. As used in this subsection,
"quarterly basis" means the Centers for Medicare and Medicaid
Services' quarterly reporting periods for the federal fiscal
year. The Department shall use the quarterly payroll-based
journal and the self-reported census to calculate the number
of hours provided per resident per day and compare this ratio

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to the minimum staffing standards required under this Section,
as impacted by any waivers granted under Section 3-303.1.
Discrepancies between job titles contained in this Section and
the payroll-based journal shall be addressed by rule. The
manner in which the Department requests payroll-based journal
information to be submitted shall align with the federal
Centers for Medicare and Medicaid Services' requirements that
allow providers to submit the quarterly data in an aggregate
manner.
(g) Monetary penalties for non-compliance. The Department
shall propose rules that are necessary to implement the
provisions of this Section, consistent with the changes made
by this amendatory Act of the 104th General Assembly, within
60 days after the effective date of this amendatory Act of the
104th General Assembly. submit proposed rules for adoption by
January 1, 2020 establishing monetary penalties for facilities
not in compliance with minimum staffing standards under this
Section. Facilities shall be required to comply with the
provisions of this subsection beginning January 1, 2025. No
monetary penalty may be issued for noncompliance prior to the
revised implementation date, which shall be January 1, 2025.
If a facility is found to be noncompliant prior to the revised
implementation date, the Department shall provide a written
notice identifying the staffing deficiencies and require the
facility to provide a sufficiently detailed correction plan
that describes proposed and completed actions the facility

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will take or has taken, including hiring actions, to address
the facility's failure to meet the statutory minimum staffing
levels. Monetary penalties shall be imposed beginning no later
than July 1, 2025, based on data for the quarter beginning July
1, 2026 through September 30, 2026 January 1, 2025 through
March 31, 2025 and quarterly thereafter. Monetary penalties
shall be assessed on a quarterly basis and established based
on a formula that calculates on a daily basis the cost of wages
and benefits for the missing staffing hours. All notices of
noncompliance shall include the computations used to determine
noncompliance and establishing the variance between minimum
staffing ratios and the Department's computations. The penalty
for the first offense shall be 125% of the cost of wages and
benefits for the missing staffing hours. The penalty shall
increase to 150% of the cost of wages and benefits for the
missing staffing hours for the second offense and 200% the
cost of wages and benefits for the missing staffing hours for
the third and all subsequent offenses. The penalty shall be
imposed regardless of whether the facility has committed other
violations of this Act during the same period that the
staffing offense occurred. The penalty may not be waived,
except where there is no more than a 10% deviation from the
staffing requirements, in which case the facility shall not
receive a violation or penalty. The Department shall:
(1) when calculating whether there is no more than a
10% deviation from the staffing requirements, determine

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the deviation based only on days of the quarter where a
facility failed to meet the minimum staffing requirements;
and
(2) only assess penalties against categories of
payroll-based journal job titles that deviate from the
staffing requirements by more than 10%. Categories include
registered nurses, licensed practical nurses, and other
payroll-based journal job titles, as determined by the
required staffing levels in subsection (e) of this Section
and as listed in subsections (a) and (a-5) of this
Section. Penalties shall not be assessed against
categories of payroll-based journal job titles that have
no more than a 10% deviation from staffing requirements.
The Department is granted discretion to waive the
violation and penalty when unforeseen circumstances have
occurred that resulted in call-offs of scheduled staff. This
provision shall be applied no more than 6 times per quarter.
Nothing in this Section diminishes a facility's right to
appeal the imposition of a monetary penalty. No facility may
appeal a notice of noncompliance issued during the revised
implementation period. The changes made to this subsection by
this amendatory Act of the 104th General Assembly in regard to
nursing home staffing fines shall apply to the July 1, 2025
fines based on data for the quarter beginning July 1, 2026
through September 30, 2026, January 1, 2025 through March 31,
2025 and quarterly thereafter.

10400SB3365ham001 - 491 - LRB104 18483 KTG 38682 a
(Source: P.A. 104-9, eff. 6-16-25.)
Section 260-15. The Illinois Public Aid Code is amended by
changing Sections 5-5.2 and 12-4.25 as follows:
(305 ILCS 5/5-5.2)
Sec. 5-5.2. Payment.
(a) All nursing facilities that are grouped pursuant to
Section 5-5.1 of this Act shall receive the same rate of
payment for similar services.
(b) It shall be a matter of State policy that the Illinois
Department shall utilize a uniform billing cycle throughout
the State for the long-term care providers.
(c) (Blank).
(c-1) Notwithstanding any other provisions of this Code,
the methodologies for reimbursement of nursing services as
provided under this Article shall no longer be applicable for
bills payable for nursing services rendered on or after a new
reimbursement system based on the Patient Driven Payment Model
(PDPM) has been fully operationalized, which shall take effect
for services provided on or after the implementation of the
PDPM reimbursement system begins. For the purposes of Public
Act 102-1035, the implementation date of the PDPM
reimbursement system and all related provisions shall be July
1, 2022 if the following conditions are met: (i) the Centers
for Medicare and Medicaid Services has approved corresponding

10400SB3365ham001 - 492 - LRB104 18483 KTG 38682 a
changes in the reimbursement system and bed assessment; and
(ii) the Department has filed rules to implement these changes
no later than June 1, 2022. Failure of the Department to file
rules to implement the changes provided in Public Act 102-1035
no later than June 1, 2022 shall result in the implementation
date being delayed to October 1, 2022.
(d) The new nursing services reimbursement methodology
utilizing the Patient Driven Payment Model, which shall be
referred to as the PDPM reimbursement system, taking effect
July 1, 2022, upon federal approval by the Centers for
Medicare and Medicaid Services, shall be based on the
following:
(1) The methodology shall be resident-centered,
facility-specific, cost-based, and based on guidance from
the Centers for Medicare and Medicaid Services.
(2) Costs shall be annually rebased and case mix index
quarterly updated. The nursing services methodology will
be assigned to the Medicaid enrolled residents on record
as of 30 days prior to the beginning of the rate period in
the Department's Medicaid Management Information System
(MMIS) as present on the last day of the second quarter
preceding the rate period based upon the Assessment
Reference Date of the Minimum Data Set (MDS).
(3) Regional wage adjustors based on the Health
Service Areas (HSA) groupings and adjusters in effect on
April 30, 2012 shall be included, except no adjuster shall

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be lower than 1.06.
(4) PDPM nursing case mix indices in effect on March
1, 2022 shall be assigned to each resident class at no less
than 0.7858 of the Centers for Medicare and Medicaid
Services PDPM unadjusted case mix values, in effect on
March 1, 2022.
(5) The pool of funds available for distribution by
case mix and the base facility rate shall be determined
using the formula contained in subsection (d-1).
(6) The Department shall establish a variable per diem
staffing add-on in accordance with the most recent
available federal staffing report, currently the Payroll
Based Journal, for the same period of time, and if
applicable adjusted for acuity using the same quarter's
MDS. The Department shall rely on Payroll Based Journals
provided to the Department of Public Health to make a
determination of non-submission. If the Department is
notified by a facility of missing or inaccurate Payroll
Based Journal data or an incorrect calculation of
staffing, the Department must make a correction as soon as
the error is verified for the applicable quarter.
Beginning October 1, 2024, the staffing percentage
used in the calculation of the per diem staffing add-on
shall be its PDPM STRIVE Staffing Ratio which equals: its
Reported Total Nurse Staffing Hours Per Resident Per Day
as published in the most recent federal staffing report

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(the Provider Information File), divided by the facility's
PDPM STRIVE Staffing Target. Each facility's PDPM STRIVE
Staffing Target is equal to .82 times the facility's
Illinois Adjusted Facility Case-Mix Hours Per Resident Per
Day. A facility's Illinois Adjusted Facility Case Mix
Hours Per Resident Per Day is equal to its Case-Mix Total
Nurse Staffing Hours Per Resident Per Day (as published in
the most recent federal Provider Information file) times
3.662 (which reflects the national resident days-weighted
mean Reported Total Nurse Staffing Hours Per Resident Per
Day as calculated using the January 2024 federal Provider
Information Files), divided by the national resident
days-weighted mean Reported Total Nurse Staffing Hours Per
Resident Per Day calculated using the most recent State US
Averages file.
Beginning January 1, 2025, the staffing percentage
used in the calculation of the per diem staffing add-on
shall be its PDPM STRIVE Staffing Ratio which equals: its
Reported Total Nurse Staffing Hours Per Resident Per Day
as published in the most recent federal staffing report
(the Provider Information File), divided by the facility's
PDPM STRIVE Staffing Target. Each facility's PDPM STRIVE
Staffing Target is equal to .7122 times the facility's
Illinois Adjusted Facility Case-Mix Hours Per Resident Per
Day. A facility's Illinois Adjusted Facility Case Mix
Hours Per Resident Per Day is equal to its Case-Mix Total

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Nurse Staffing Hours Per Resident Per Day (as published in
the most recent federal staffing report Provider
Information file) times 3.79 (which is the Reported Total
Nurse Staffing Hours Per Resident Per Day for the Nation
as reported the January 2024 State US Averages file),
divided by the Reported Total Nurse Staffing Hours Per
Resident Per Day for the Nation as reported in the most
recent State US Averages file.
(6.5) Beginning July 1, 2024, the paid per diem
staffing add-on shall be the paid per diem staffing add-on
in effect April 1, 2024. For dates beginning October 1,
2024 and through September 30, 2025, the denominator for
the staffing percentage shall be the lesser of the
facility's PDPM STRIVE Staffing Target and:
(A) For the quarter beginning October 1, 2024, the
sum of 20% of the facility's PDPM STRIVE Staffing
Target and 80% of the facility's Case-Mix Total Nurse
Staffing Hours Per Resident Per Day (as published in
the January 2024 federal staffing report).
(B) For the quarter beginning January 1, 2025, the
sum of 40% of the facility's PDPM STRIVE Staffing
Target and 60% of the facility's Case-Mix Total Nurse
Staffing Hours Per Resident Per Day (as published in
the January 2024 federal staffing report).
(C) For the quarter beginning March 1, 2025, the
sum of 60% of the facility's PDPM STRIVE Staffing

10400SB3365ham001 - 496 - LRB104 18483 KTG 38682 a
Target and 40% of the facility's Case-Mix Total Nurse
Staffing Hours Per Resident Per Day (as published in
the January 2024 federal staffing report).
(D) For the quarter beginning July 1, 2025, the
sum of 80% of the facility's PDPM STRIVE Staffing
Target and 20% of the facility's Case-Mix Total Nurse
Staffing Hours Per Resident Per Day (as published in
the January 2024 federal staffing report).
Facilities with at least 70% of the staffing
indicated by the STRIVE study shall be paid a per diem
add-on of $9, increasing by equivalent steps for each
whole percentage point until the facilities reach a per
diem of $16.52. Facilities with at least 80% of the
staffing indicated by the STRIVE study shall be paid a per
diem add-on of $16.52, increasing by equivalent steps for
each whole percentage point until the facilities reach a
per diem add-on of $25.77. Facilities with at least 92% of
the staffing indicated by the STRIVE study shall be paid a
per diem add-on of $25.77, increasing by equivalent steps
for each whole percentage point until the facilities reach
a per diem add-on of $30.98. Facilities with at least 100%
of the staffing indicated by the STRIVE study shall be
paid a per diem add-on of $30.98, increasing by equivalent
steps for each whole percentage point until the facilities
reach a per diem add-on of $36.44. Facilities with at
least 110% of the staffing indicated by the STRIVE study

10400SB3365ham001 - 497 - LRB104 18483 KTG 38682 a
shall be paid a per diem add-on of $36.44, increasing by
equivalent steps for each whole percentage point until the
facilities reach a per diem add-on of $38.68. Facilities
with at least 125% or higher of the staffing indicated by
the STRIVE study shall be paid a per diem add-on of $38.68.
No nursing facility's variable staffing per diem add-on
shall be reduced by more than 5% in 2 consecutive
quarters. For the quarters beginning July 1, 2022 and
October 1, 2022, no facility's variable per diem staffing
add-on shall be calculated at a rate lower than 85% of the
staffing indicated by the STRIVE study. No facility below
70% of the staffing indicated by the STRIVE study shall
receive a variable per diem staffing add-on after December
31, 2022.
Beginning January 1, 2027, a $2.25 rate increase shall
be added to each STRIVE staffing per diem add-on under
subparagraph (D) of this paragraph (6.5) for facilities
with at least 80% of the staffing indicated by the STRIVE
study.
(7) For dates of services beginning July 1, 2022, the
PDPM nursing component per diem for each nursing facility
shall be the product of the facility's (i) statewide PDPM
nursing base per diem rate, $92.25, adjusted for the
facility average PDPM case mix index calculated quarterly
and (ii) the regional wage adjuster, and then add the
Medicaid access adjustment as defined in (e-3) of this

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Section. Transition rates for services provided between
July 1, 2022 and October 1, 2023 shall be the greater of
the PDPM nursing component per diem or:
(A) for the quarter beginning July 1, 2022, the
RUG-IV nursing component per diem;
(B) for the quarter beginning October 1, 2022, the
sum of the RUG-IV nursing component per diem
multiplied by 0.80 and the PDPM nursing component per
diem multiplied by 0.20;
(C) for the quarter beginning January 1, 2023, the
sum of the RUG-IV nursing component per diem
multiplied by 0.60 and the PDPM nursing component per
diem multiplied by 0.40;
(D) for the quarter beginning April 1, 2023, the
sum of the RUG-IV nursing component per diem
multiplied by 0.40 and the PDPM nursing component per
diem multiplied by 0.60;
(E) for the quarter beginning July 1, 2023, the
sum of the RUG-IV nursing component per diem
multiplied by 0.20 and the PDPM nursing component per
diem multiplied by 0.80; or
(F) for the quarter beginning October 1, 2023 and
each subsequent quarter, the transition rate shall end
and a nursing facility shall be paid 100% of the PDPM
nursing component per diem.
(d-1) Calculation of base year Statewide RUG-IV nursing

10400SB3365ham001 - 499 - LRB104 18483 KTG 38682 a
base per diem rate.
(1) Base rate spending pool shall be:
(A) The base year resident days which are
calculated by multiplying the number of Medicaid
residents in each nursing home as indicated in the MDS
data defined in paragraph (4) by 365.
(B) Each facility's nursing component per diem in
effect on July 1, 2012 shall be multiplied by
subsection (A).
(C) Thirteen million is added to the product of
subparagraph (A) and subparagraph (B) to adjust for
the exclusion of nursing homes defined in paragraph
(5).
(2) For each nursing home with Medicaid residents as
indicated by the MDS data defined in paragraph (4),
weighted days adjusted for case mix and regional wage
adjustment shall be calculated. For each home this
calculation is the product of:
(A) Base year resident days as calculated in
subparagraph (A) of paragraph (1).
(B) The nursing home's regional wage adjustor
based on the Health Service Areas (HSA) groupings and
adjustors in effect on April 30, 2012.
(C) Facility weighted case mix which is the number
of Medicaid residents as indicated by the MDS data
defined in paragraph (4) multiplied by the associated

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case weight for the RUG-IV 48 grouper model using
standard RUG-IV procedures for index maximization.
(D) The sum of the products calculated for each
nursing home in subparagraphs (A) through (C) above
shall be the base year case mix, rate adjusted
weighted days.
(3) The Statewide RUG-IV nursing base per diem rate:
(A) on January 1, 2014 shall be the quotient of the
paragraph (1) divided by the sum calculated under
subparagraph (D) of paragraph (2);
(B) on and after July 1, 2014 and until July 1,
2022, shall be the amount calculated under
subparagraph (A) of this paragraph (3) plus $1.76; and
(C) beginning July 1, 2022 and thereafter, $7
shall be added to the amount calculated under
subparagraph (B) of this paragraph (3) of this
Section.
(4) Minimum Data Set (MDS) comprehensive assessments
for Medicaid residents on the last day of the quarter used
to establish the base rate.
(5) Nursing facilities designated as of July 1, 2012
by the Department as "Institutions for Mental Disease"
shall be excluded from all calculations under this
subsection. The data from these facilities shall not be
used in the computations described in paragraphs (1)
through (4) above to establish the base rate.

10400SB3365ham001 - 501 - LRB104 18483 KTG 38682 a
(e) Beginning July 1, 2014, the Department shall allocate
funding in the amount up to $10,000,000 for per diem add-ons to
the RUGS methodology for dates of service on and after July 1,
2014:
(1) $0.63 for each resident who scores in I4200
Alzheimer's Disease or I4800 non-Alzheimer's Dementia.
(2) $2.67 for each resident who scores either a "1" or
"2" in any items S1200A through S1200I and also scores in
RUG groups PA1, PA2, BA1, or BA2.
(e-1) (Blank).
(e-2) For dates of services beginning January 1, 2014 and
ending September 30, 2023, the RUG-IV nursing component per
diem for a nursing home shall be the product of the statewide
RUG-IV nursing base per diem rate, the facility average case
mix index, and the regional wage adjustor. For dates of
service beginning July 1, 2022 and ending September 30, 2023,
the Medicaid access adjustment described in subsection (e-3)
shall be added to the product.
(e-3) A Medicaid Access Adjustment of $4 adjusted for the
facility average PDPM case mix index calculated quarterly
shall be added to the statewide PDPM nursing per diem for all
facilities with annual Medicaid bed days of at least 70% of all
occupied bed days adjusted quarterly. For each new calendar
year and for the 6-month period beginning July 1, 2022, the
percentage of a facility's occupied bed days comprised of
Medicaid bed days shall be determined by the Department

10400SB3365ham001 - 502 - LRB104 18483 KTG 38682 a
quarterly. For dates of service beginning January 1, 2023, the
Medicaid Access Adjustment shall be increased to $4.75. This
subsection shall be inoperative on and after December 31, 2029
January 1, 2028.
(e-3.5) For dates of service beginning January 1, 2027,
the Medicaid Access Adjustment shall be increased by $5.55 to
$10.30 per diem for those facilities with at least 70% of the
staffing indicated by the STRIVE study as described in
subparagraph (D) of paragraph (6.5) of subsection (d). A
facility shall be eligible for Medicaid Access Adjustment
described in this subsection (e-3.5) only if the facility
demonstrates compliance with the training requirements for
staff outlined in Section 3-130 of the Nursing Home Care Act.
This subsection (e-3.5) shall be inoperative on and after
December 31, 2029.
(e-3.6) For dates of service beginning January 1, 2027,
facilities located outside of Rate Areas 6, 7, and 8 that have
Medicaid bed days of at least 65% of all occupied bed days
adjusted quarterly shall qualify for the Medicaid Access
Adjustment described in subsections (e-3) and (e-3.5).
Facilities located inside Rate Areas 6, 7, and 8 shall have
their threshold remain at 70% for all qualifying facilities
described in subsections (e-3) and (e-3.5). This subsection
(e-3.6) shall be inoperative on and after December 31, 2029.
(e-4) Subject to federal approval, on and after January 1,
2024, the Department shall increase the rate add-on at

10400SB3365ham001 - 503 - LRB104 18483 KTG 38682 a
paragraph (7) subsection (a) under 89 Ill. Adm. Code 147.335
for ventilator services from $208 per day to $481 per day.
Payment is subject to the criteria and requirements under 89
Ill. Adm. Code 147.335.
(f) (Blank).
(g) Notwithstanding any other provision of this Code, on
and after July 1, 2012, for facilities not designated by the
Department of Healthcare and Family Services as "Institutions
for Mental Disease", rates effective May 1, 2011 shall be
adjusted as follows:
(1) (Blank);
(2) (Blank);
(3) Facility rates for the capital and support
components shall be reduced by 1.7%.
(h) Notwithstanding any other provision of this Code, on
and after July 1, 2012, nursing facilities designated by the
Department of Healthcare and Family Services as "Institutions
for Mental Disease" and "Institutions for Mental Disease" that
are facilities licensed under the Specialized Mental Health
Rehabilitation Act of 2013 shall have the nursing,
socio-developmental, capital, and support components of their
reimbursement rate effective May 1, 2011 reduced in total by
2.7%.
(i) On and after July 1, 2014, the reimbursement rates for
the support component of the nursing facility rate for
facilities licensed under the Nursing Home Care Act as skilled

10400SB3365ham001 - 504 - LRB104 18483 KTG 38682 a
or intermediate care facilities shall be the rate in effect on
June 30, 2014 increased by 8.17%.
(i-1) Subject to federal approval, on and after January 1,
2024, the reimbursement rates for the support component of the
nursing facility rate for facilities licensed under the
Nursing Home Care Act as skilled or intermediate care
facilities shall be the rate in effect on June 30, 2023
increased by 12%.
(j) Notwithstanding any other provision of law, subject to
federal approval, effective July 1, 2019, sufficient funds
shall be allocated for changes to rates for facilities
licensed under the Nursing Home Care Act as skilled nursing
facilities or intermediate care facilities for dates of
services on and after July 1, 2019: (i) to establish, through
June 30, 2022 a per diem add-on to the direct care per diem
rate not to exceed $70,000,000 annually in the aggregate
taking into account federal matching funds for the purpose of
addressing the facility's unique staffing needs, adjusted
quarterly and distributed by a weighted formula based on
Medicaid bed days on the last day of the second quarter
preceding the quarter for which the rate is being adjusted.
Beginning July 1, 2022, the annual $70,000,000 described in
the preceding sentence shall be dedicated to the variable per
diem add-on for staffing under paragraph (6) of subsection
(d); and (ii) in an amount not to exceed $170,000,000 annually
in the aggregate taking into account federal matching funds to

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permit the support component of the nursing facility rate to
be updated as follows:
(1) 80%, or $136,000,000, of the funds shall be used
to update each facility's rate in effect on June 30, 2019
using the most recent cost reports on file, which have had
a limited review conducted by the Department of Healthcare
and Family Services and will not hold up enacting the rate
increase, with the Department of Healthcare and Family
Services.
(2) After completing the calculation in paragraph (1),
any facility whose rate is less than the rate in effect on
June 30, 2019 shall have its rate restored to the rate in
effect on June 30, 2019 from the 20% of the funds set
aside.
(3) The remainder of the 20%, or $34,000,000, shall be
used to increase each facility's rate by an equal
percentage.
(k) During the first quarter of State Fiscal Year 2020,
the Department of Healthcare of Family Services must convene a
technical advisory group consisting of members of all trade
associations representing Illinois skilled nursing providers
to discuss changes necessary with federal implementation of
Medicare's Patient-Driven Payment Model. Implementation of
Medicare's Patient-Driven Payment Model shall, by September 1,
2020, end the collection of the MDS data that is necessary to
maintain the current RUG-IV Medicaid payment methodology. The

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technical advisory group must consider a revised reimbursement
methodology that takes into account transparency,
accountability, actual staffing as reported under the
federally required Payroll Based Journal system, changes to
the minimum wage, adequacy in coverage of the cost of care, and
a quality component that rewards quality improvements.
(l) The Department shall establish per diem add-on
payments to improve the quality of care delivered by
facilities, including:
(1) Incentive payments determined by facility
performance on specified quality measures in an initial
amount of $70,000,000. Nothing in this subsection shall be
construed to limit the quality of care payments in the
aggregate statewide to $70,000,000, and, if quality of
care has improved across nursing facilities, the
Department shall adjust those add-on payments accordingly.
The quality payment methodology described in this
subsection must be used for at least State Fiscal Year
2023. Beginning with the quarter starting July 1, 2023,
the Department may add, remove, or change quality metrics
and make associated changes to the quality payment
methodology as outlined in subparagraph (E). Facilities
designated by the Centers for Medicare and Medicaid
Services as a special focus facility or a hospital-based
nursing home do not qualify for quality payments.
(A) Each quality pool must be distributed by

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assigning a quality weighted score for each nursing
home which is calculated by multiplying the nursing
home's quality base period Medicaid days by the
nursing home's star rating weight in that period.
(B) Star rating weights are assigned based on the
nursing home's star rating for the LTS quality star
rating. As used in this subparagraph, "LTS quality
star rating" means the long-term stay quality rating
for each nursing facility, as assigned by the Centers
for Medicare and Medicaid Services under the Five-Star
Quality Rating System. The rating is a number ranging
from 0 (lowest) to 5 (highest).
(i) Zero-star or one-star rating has a weight
of 0.
(ii) Two-star rating has a weight of 0.75.
(iii) Three-star rating has a weight of 1.5.
(iv) Four-star rating has a weight of 2.5.
(v) Five-star rating has a weight of 3.5.
(C) Each nursing home's quality weight score is
divided by the sum of all quality weight scores for
qualifying nursing homes to determine the proportion
of the quality pool to be paid to the nursing home.
(D) The quality pool is no less than $70,000,000
annually or $17,500,000 per quarter. The Department
shall publish on its website the estimated payments
and the associated weights for each facility 45 days

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prior to when the initial payments for the quarter are
to be paid. The Department shall assign each facility
the most recent and applicable quarter's STAR value
unless the facility notifies the Department within 15
days of an issue and the facility provides reasonable
evidence demonstrating its timely compliance with
federal data submission requirements for the quarter
of record. If such evidence cannot be provided to the
Department, the STAR rating assigned to the facility
shall be reduced by one from the prior quarter.
(E) The Department shall review quality metrics
used for payment of the quality pool and make
recommendations for any associated changes to the
methodology for distributing quality pool payments in
consultation with associations representing long-term
care providers, consumer advocates, organizations
representing workers of long-term care facilities, and
payors. The Department may establish, by rule, changes
to the methodology for distributing quality pool
payments.
(F) The Department shall disburse quality pool
payments from the Long-Term Care Provider Fund on a
monthly basis in amounts proportional to the total
quality pool payment determined for the quarter.
(G) The Department shall publish any changes in
the methodology for distributing quality pool payments

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prior to the beginning of the measurement period or
quality base period for any metric added to the
distribution's methodology.
(2) Payments based on CNA tenure, promotion, and CNA
training for the purpose of increasing CNA compensation.
It is the intent of this subsection that payments made in
accordance with this paragraph be directly incorporated
into increased compensation for CNAs. As used in this
paragraph, "CNA" means a certified nursing assistant as
that term is described in Section 3-206 of the Nursing
Home Care Act, Section 3-206 of the ID/DD Community Care
Act, and Section 3-206 of the MC/DD Act. The Department
shall establish, by rule, payments to nursing facilities
equal to Medicaid's share of the tenure wage increments
specified in this paragraph for all reported CNA employee
hours compensated according to a posted schedule
consisting of increments at least as large as those
specified in this paragraph. The increments are as
follows: an additional $1.50 per hour for CNAs with at
least one and less than 2 years' experience plus another
$1 per hour for each additional year of experience up to a
maximum of $6.50 for CNAs with at least 6 years of
experience. For purposes of this paragraph, Medicaid's
share shall be the ratio determined by paid Medicaid bed
days divided by total bed days for the applicable time
period used in the calculation. In addition, and additive

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to any tenure increments paid as specified in this
paragraph, the Department shall establish, by rule,
payments supporting Medicaid's share of the
promotion-based wage increments for CNA employee hours
compensated for that promotion with at least a $1.50
hourly increase. Medicaid's share shall be established as
it is for the tenure increments described in this
paragraph. Qualifying promotions shall be defined by the
Department in rules for an expected 10-15% subset of CNAs
assigned intermediate, specialized, or added roles such as
CNA trainers, CNA scheduling "captains", and CNA
specialists for resident conditions like dementia or
memory care or behavioral health.
(m) The Department shall work with nursing facility
industry representatives to design policies and procedures to
permit facilities to address the integrity of data from
federal reporting sites used by the Department in setting
facility rates.
(Source: P.A. 102-77, eff. 7-9-21; 102-558, eff. 8-20-21;
102-1035, eff. 5-31-22; 102-1118, eff. 1-18-23; 103-102,
Article 40, Section 40-5, eff. 1-1-24; 103-102, Article 50,
Section 50-5, eff. 1-1-24; 103-593, eff. 6-7-24; 103-605, eff.
7-1-24; 103-1075, eff. 3-21-25.)
(305 ILCS 5/12-4.25) (from Ch. 23, par. 12-4.25)
Sec. 12-4.25. Medical assistance program; vendor

10400SB3365ham001 - 511 - LRB104 18483 KTG 38682 a
participation.
(A) The Illinois Department may deny, suspend, or
terminate the eligibility of any person, firm, corporation,
association, agency, institution or other legal entity to
participate as a vendor of goods or services to recipients
under the medical assistance program under Article V, or may
exclude any such person or entity from participation as such a
vendor, and may deny, suspend, or recover payments, if after
reasonable notice and opportunity for a hearing the Illinois
Department finds:
(a) Such vendor is not complying with the Department's
policy or rules and regulations, or with the terms and
conditions prescribed by the Illinois Department in its
vendor agreement, which document shall be developed by the
Department as a result of negotiations with each vendor
category, including physicians, hospitals, long term care
facilities, pharmacists, optometrists, podiatric
physicians, and dentists setting forth the terms and
conditions applicable to the participation of each vendor
group in the program; or
(b) Such vendor has failed to keep or make available
for inspection, audit or copying, after receiving a
written request from the Illinois Department, such records
regarding payments claimed for providing services. This
section does not require vendors to make available patient
records of patients for whom services are not reimbursed

10400SB3365ham001 - 512 - LRB104 18483 KTG 38682 a
under this Code; or
(c) Such vendor has failed to furnish any information
requested by the Department regarding payments for
providing goods or services; or
(d) Such vendor has knowingly made, or caused to be
made, any false statement or representation of a material
fact in connection with the administration of the medical
assistance program; or
(e) Such vendor has furnished goods or services to a
recipient which are (1) in excess of need, (2) harmful, or
(3) of grossly inferior quality, all of such
determinations to be based upon competent medical judgment
and evaluations; or
(f) The vendor; a person with management
responsibility for a vendor; an officer or person owning,
either directly or indirectly, 5% or more of the shares of
stock or other evidences of ownership in a corporate
vendor; an owner of a sole proprietorship which is a
vendor; or a partner in a partnership which is a vendor,
either:
(1) was previously terminated, suspended, or
excluded from participation in the Illinois medical
assistance program, or was terminated, suspended, or
excluded from participation in another state or
federal medical assistance or health care program; or
(2) was a person with management responsibility

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for a vendor previously terminated, suspended, or
excluded from participation in the Illinois medical
assistance program, or terminated, suspended, or
excluded from participation in another state or
federal medical assistance or health care program
during the time of conduct which was the basis for that
vendor's termination, suspension, or exclusion; or
(3) was an officer, or person owning, either
directly or indirectly, 5% or more of the shares of
stock or other evidences of ownership in a corporate
or limited liability company vendor previously
terminated, suspended, or excluded from participation
in the Illinois medical assistance program, or
terminated, suspended, or excluded from participation
in a state or federal medical assistance or health
care program during the time of conduct which was the
basis for that vendor's termination, suspension, or
exclusion; or
(4) was an owner of a sole proprietorship or
partner of a partnership previously terminated,
suspended, or excluded from participation in the
Illinois medical assistance program, or terminated,
suspended, or excluded from participation in a state
or federal medical assistance or health care program
during the time of conduct which was the basis for that
vendor's termination, suspension, or exclusion; or

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(f-1) Such vendor has a delinquent debt owed to the
Illinois Department; or
(g) The vendor; a person with management
responsibility for a vendor; an officer or person owning,
either directly or indirectly, 5% or more of the shares of
stock or other evidences of ownership in a corporate or
limited liability company vendor; an owner of a sole
proprietorship which is a vendor; or a partner in a
partnership which is a vendor, either:
(1) has engaged in practices prohibited by
applicable federal or State law or regulation; or
(2) was a person with management responsibility
for a vendor at the time that such vendor engaged in
practices prohibited by applicable federal or State
law or regulation; or
(3) was an officer, or person owning, either
directly or indirectly, 5% or more of the shares of
stock or other evidences of ownership in a vendor at
the time such vendor engaged in practices prohibited
by applicable federal or State law or regulation; or
(4) was an owner of a sole proprietorship or
partner of a partnership which was a vendor at the time
such vendor engaged in practices prohibited by
applicable federal or State law or regulation; or
(h) The direct or indirect ownership of the vendor
(including the ownership of a vendor that is a sole

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proprietorship, a partner's interest in a vendor that is a
partnership, or ownership of 5% or more of the shares of
stock or other evidences of ownership in a corporate
vendor) has been transferred by an individual who is
terminated, suspended, or excluded or barred from
participating as a vendor to the individual's spouse,
child, brother, sister, parent, grandparent, grandchild,
uncle, aunt, niece, nephew, cousin, or relative by
marriage.
(A-5) The Illinois Department may deny, suspend, or
terminate the eligibility of any person, firm, corporation,
association, agency, institution, or other legal entity to
participate as a vendor of goods or services to recipients
under the medical assistance program under Article V, or may
exclude any such person or entity from participation as such a
vendor, if, after reasonable notice and opportunity for a
hearing, the Illinois Department finds that the vendor; a
person with management responsibility for a vendor; an officer
or person owning, either directly or indirectly, 5% or more of
the shares of stock or other evidences of ownership in a
corporate vendor; an owner of a sole proprietorship that is a
vendor; or a partner in a partnership that is a vendor has been
convicted of an offense based on fraud or willful
misrepresentation related to any of the following:
(1) The medical assistance program under Article V of
this Code.

10400SB3365ham001 - 516 - LRB104 18483 KTG 38682 a
(2) A medical assistance or health care program in
another state.
(3) The Medicare program under Title XVIII of the
Social Security Act.
(4) The provision of health care services.
(5) A violation of this Code, as provided in Article
VIIIA, or another state or federal medical assistance
program or health care program.
(A-10) The Illinois Department may deny, suspend, or
terminate the eligibility of any person, firm, corporation,
association, agency, institution, or other legal entity to
participate as a vendor of goods or services to recipients
under the medical assistance program under Article V, or may
exclude any such person or entity from participation as such a
vendor, if, after reasonable notice and opportunity for a
hearing, the Illinois Department finds that (i) the vendor,
(ii) a person with management responsibility for a vendor,
(iii) an officer or person owning, either directly or
indirectly, 5% or more of the shares of stock or other
evidences of ownership in a corporate vendor, (iv) an owner of
a sole proprietorship that is a vendor, or (v) a partner in a
partnership that is a vendor has been convicted of an offense
related to any of the following:
(1) Murder.
(2) A Class X felony under the Criminal Code of 1961 or
the Criminal Code of 2012.

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(3) Sexual misconduct that may subject recipients to
an undue risk of harm.
(4) A criminal offense that may subject recipients to
an undue risk of harm.
(5) A crime of fraud or dishonesty.
(6) A crime involving a controlled substance.
(7) A misdemeanor relating to fraud, theft,
embezzlement, breach of fiduciary responsibility, or other
financial misconduct related to a health care program.
(A-15) The Illinois Department may deny the eligibility of
any person, firm, corporation, association, agency,
institution, or other legal entity to participate as a vendor
of goods or services to recipients under the medical
assistance program under Article V if, after reasonable notice
and opportunity for a hearing, the Illinois Department finds:
(1) The applicant or any person with management
responsibility for the applicant; an officer or member of
the board of directors of an applicant; an entity owning
(directly or indirectly) 5% or more of the shares of stock
or other evidences of ownership in a corporate vendor
applicant; an owner of a sole proprietorship applicant; a
partner in a partnership applicant; or a technical or
other advisor to an applicant has a debt owed to the
Illinois Department, and no payment arrangements
acceptable to the Illinois Department have been made by
the applicant.

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(2) The applicant or any person with management
responsibility for the applicant; an officer or member of
the board of directors of an applicant; an entity owning
(directly or indirectly) 5% or more of the shares of stock
or other evidences of ownership in a corporate vendor
applicant; an owner of a sole proprietorship applicant; a
partner in a partnership vendor applicant; or a technical
or other advisor to an applicant was (i) a person with
management responsibility, (ii) an officer or member of
the board of directors of an applicant, (iii) an entity
owning (directly or indirectly) 5% or more of the shares
of stock or other evidences of ownership in a corporate
vendor, (iv) an owner of a sole proprietorship, (v) a
partner in a partnership vendor, (vi) a technical or other
advisor to a vendor, during a period of time where the
conduct of that vendor resulted in a debt owed to the
Illinois Department, and no payment arrangements
acceptable to the Illinois Department have been made by
that vendor.
(3) There is a credible allegation of the use,
transfer, or lease of assets of any kind to an applicant
from a current or prior vendor who has a debt owed to the
Illinois Department, no payment arrangements acceptable to
the Illinois Department have been made by that vendor or
the vendor's alternate payee, and the applicant knows or
should have known of such debt.

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(4) There is a credible allegation of a transfer of
management responsibilities, or direct or indirect
ownership, to an applicant from a current or prior vendor
who has a debt owed to the Illinois Department, and no
payment arrangements acceptable to the Illinois Department
have been made by that vendor or the vendor's alternate
payee, and the applicant knows or should have known of
such debt.
(5) There is a credible allegation of the use,
transfer, or lease of assets of any kind to an applicant
who is a spouse, child, brother, sister, parent,
grandparent, grandchild, uncle, aunt, niece, relative by
marriage, nephew, cousin, or relative of a current or
prior vendor who has a debt owed to the Illinois
Department and no payment arrangements acceptable to the
Illinois Department have been made.
(6) There is a credible allegation that the
applicant's previous affiliations with a provider of
medical services that has an uncollected debt, a provider
that has been or is subject to a payment suspension under a
federal health care program, or a provider that has been
previously excluded from participation in the medical
assistance program, poses a risk of fraud, waste, or abuse
to the Illinois Department.
As used in this subsection, "credible allegation" is
defined to include an allegation from any source, including,

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but not limited to, fraud hotline complaints, claims data
mining, patterns identified through provider audits, civil
actions filed under the Illinois False Claims Act, and law
enforcement investigations. An allegation is considered to be
credible when it has indicia of reliability.
(B) The Illinois Department shall deny, suspend or
terminate the eligibility of any person, firm, corporation,
association, agency, institution or other legal entity to
participate as a vendor of goods or services to recipients
under the medical assistance program under Article V, or may
exclude any such person or entity from participation as such a
vendor:
(1) immediately, if such vendor is not properly
licensed, certified, or authorized;
(2) within 30 days of the date when such vendor's
professional license, certification or other authorization
has been refused renewal, restricted, revoked, suspended,
or otherwise terminated; or
(3) if such vendor has been convicted of a violation
of this Code, as provided in Article VIIIA.
(C) Upon termination, suspension, or exclusion of a vendor
of goods or services from participation in the medical
assistance program authorized by this Article, a person with
management responsibility for such vendor during the time of
any conduct which served as the basis for that vendor's
termination, suspension, or exclusion is barred from

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participation in the medical assistance program.
Upon termination, suspension, or exclusion of a corporate
vendor, the officers and persons owning, directly or
indirectly, 5% or more of the shares of stock or other
evidences of ownership in the vendor during the time of any
conduct which served as the basis for that vendor's
termination, suspension, or exclusion are barred from
participation in the medical assistance program. A person who
owns, directly or indirectly, 5% or more of the shares of stock
or other evidences of ownership in a terminated, suspended, or
excluded vendor may not transfer his or her ownership interest
in that vendor to his or her spouse, child, brother, sister,
parent, grandparent, grandchild, uncle, aunt, niece, nephew,
cousin, or relative by marriage.
Upon termination, suspension, or exclusion of a sole
proprietorship or partnership, the owner or partners during
the time of any conduct which served as the basis for that
vendor's termination, suspension, or exclusion are barred from
participation in the medical assistance program. The owner of
a terminated, suspended, or excluded vendor that is a sole
proprietorship, and a partner in a terminated, suspended, or
excluded vendor that is a partnership, may not transfer his or
her ownership or partnership interest in that vendor to his or
her spouse, child, brother, sister, parent, grandparent,
grandchild, uncle, aunt, niece, nephew, cousin, or relative by
marriage.

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A person who owns, directly or indirectly, 5% or more of
the shares of stock or other evidences of ownership in a
corporate or limited liability company vendor who owes a debt
to the Department, if that vendor has not made payment
arrangements acceptable to the Department, shall not transfer
his or her ownership interest in that vendor, or vendor assets
of any kind, to his or her spouse, child, brother, sister,
parent, grandparent, grandchild, uncle, aunt, niece, nephew,
cousin, or relative by marriage.
Rules adopted by the Illinois Department to implement
these provisions shall specifically include a definition of
the term "management responsibility" as used in this Section.
Such definition shall include, but not be limited to, typical
job titles, and duties and descriptions which will be
considered as within the definition of individuals with
management responsibility for a provider.
A vendor or a prior vendor who has been terminated,
excluded, or suspended from the medical assistance program, or
from another state or federal medical assistance or health
care program, and any individual currently or previously
barred from the medical assistance program, or from another
state or federal medical assistance or health care program, as
a result of being an officer or a person owning, directly or
indirectly, 5% or more of the shares of stock or other
evidences of ownership in a corporate or limited liability
company vendor during the time of any conduct which served as

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the basis for that vendor's termination, suspension, or
exclusion, may be required to post a surety bond as part of a
condition of enrollment or participation in the medical
assistance program. The Illinois Department shall establish,
by rule, the criteria and requirements for determining when a
surety bond must be posted and the value of the bond.
A vendor or a prior vendor who has a debt owed to the
Illinois Department and any individual currently or previously
barred from the medical assistance program, or from another
state or federal medical assistance or health care program, as
a result of being an officer or a person owning, directly or
indirectly, 5% or more of the shares of stock or other
evidences of ownership in that corporate or limited liability
company vendor during the time of any conduct which served as
the basis for the debt, may be required to post a surety bond
as part of a condition of enrollment or participation in the
medical assistance program. The Illinois Department shall
establish, by rule, the criteria and requirements for
determining when a surety bond must be posted and the value of
the bond.
(D) If a vendor has been suspended from the medical
assistance program under Article V of the Code, the Director
may require that such vendor correct any deficiencies which
served as the basis for the suspension. The Director shall
specify in the suspension order a specific period of time,
which shall not exceed one year from the date of the order,

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during which a suspended vendor shall not be eligible to
participate. At the conclusion of the period of suspension the
Director shall reinstate such vendor, unless he finds that
such vendor has not corrected deficiencies upon which the
suspension was based.
If a vendor has been terminated, suspended, or excluded
from the medical assistance program under Article V, such
vendor shall be barred from participation for at least one
year, except that if a vendor has been terminated, suspended,
or excluded based on a conviction of a violation of Article
VIIIA or a conviction of a felony based on fraud or a willful
misrepresentation related to (i) the medical assistance
program under Article V, (ii) a federal or another state's
medical assistance or health care program, or (iii) the
provision of health care services, then the vendor shall be
barred from participation for 5 years or for the length of the
vendor's sentence for that conviction, whichever is longer. At
the end of one year a vendor who has been terminated,
suspended, or excluded may apply for reinstatement to the
program. Upon proper application to be reinstated such vendor
may be deemed eligible by the Director providing that such
vendor meets the requirements for eligibility under this Code.
If such vendor is deemed not eligible for reinstatement, he
shall be barred from again applying for reinstatement for one
year from the date his application for reinstatement is
denied.

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A vendor whose termination, suspension, or exclusion from
participation in the Illinois medical assistance program under
Article V was based solely on an action by a governmental
entity other than the Illinois Department may, upon
reinstatement by that governmental entity or upon reversal of
the termination, suspension, or exclusion, apply for
rescission of the termination, suspension, or exclusion from
participation in the Illinois medical assistance program. Upon
proper application for rescission, the vendor may be deemed
eligible by the Director if the vendor meets the requirements
for eligibility under this Code.
If a vendor has been terminated, suspended, or excluded
and reinstated to the medical assistance program under Article
V and the vendor is terminated, suspended, or excluded a
second or subsequent time from the medical assistance program,
the vendor shall be barred from participation for at least 2
years, except that if a vendor has been terminated, suspended,
or excluded a second time based on a conviction of a violation
of Article VIIIA or a conviction of a felony based on fraud or
a willful misrepresentation related to (i) the medical
assistance program under Article V, (ii) a federal or another
state's medical assistance or health care program, or (iii)
the provision of health care services, then the vendor shall
be barred from participation for life. At the end of 2 years, a
vendor who has been terminated, suspended, or excluded may
apply for reinstatement to the program. Upon application to be

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reinstated, the vendor may be deemed eligible if the vendor
meets the requirements for eligibility under this Code. If the
vendor is deemed not eligible for reinstatement, the vendor
shall be barred from again applying for reinstatement for 2
years from the date the vendor's application for reinstatement
is denied.
(E) The Illinois Department may recover money improperly
or erroneously paid, or overpayments, either by setoff,
crediting against future billings or by requiring direct
repayment to the Illinois Department. The Illinois Department
may suspend or deny payment, in whole or in part, if such
payment would be improper or erroneous or would otherwise
result in overpayment.
(1) Payments may be suspended, denied, or recovered
from a vendor or alternate payee: (i) for services
rendered in violation of the Illinois Department's
provider notices, statutes, rules, and regulations; (ii)
for services rendered in violation of the terms and
conditions prescribed by the Illinois Department in its
vendor agreement; (iii) for any vendor who fails to grant
the Office of Inspector General timely access to full and
complete records, including, but not limited to, records
relating to recipients under the medical assistance
program for the most recent 6 years, in accordance with
Section 140.28 of Title 89 of the Illinois Administrative
Code, and other information for the purpose of audits,

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investigations, or other program integrity functions,
after reasonable written request by the Inspector General;
this subsection (E) does not require vendors to make
available the medical records of patients for whom
services are not reimbursed under this Code or to provide
access to medical records more than 6 years old; (iv) when
the vendor has knowingly made, or caused to be made, any
false statement or representation of a material fact in
connection with the administration of the medical
assistance program; or (v) when the vendor previously
rendered services while terminated, suspended, or excluded
from participation in the medical assistance program or
while terminated or excluded from participation in another
state or federal medical assistance or health care
program.
(2) Notwithstanding any other provision of law, if a
vendor has the same taxpayer identification number
(assigned under Section 6109 of the Internal Revenue Code
of 1986) as is assigned to a vendor with past-due
financial obligations to the Illinois Department, the
Illinois Department may make any necessary adjustments to
payments to that vendor in order to satisfy any past-due
obligations, regardless of whether the vendor is assigned
a different billing number under the medical assistance
program.
(E-5) Civil monetary penalties.

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(1) As used in this subsection (E-5):
(a) "Knowingly" means that a person, with respect
to information: (i) has actual knowledge of the
information; (ii) acts in deliberate ignorance of the
truth or falsity of the information; or (iii) acts in
reckless disregard of the truth or falsity of the
information. No proof of specific intent to defraud is
required.
(b) "Overpayment" means any funds that a person
receives or retains from the medical assistance
program to which the person, after applicable
reconciliation, is not entitled under this Code.
(c) "Remuneration" means the offer or transfer of
items or services for free or for other than fair
market value by a person; however, remuneration does
not include items or services of a nominal value of no
more than $10 per item or service, or $50 in the
aggregate on an annual basis, or any other offer or
transfer of items or services as determined by the
Department.
(d) "Should know" means that a person, with
respect to information: (i) acts in deliberate
ignorance of the truth or falsity of the information;
or (ii) acts in reckless disregard of the truth or
falsity of the information. No proof of specific
intent to defraud is required.

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(2) Any person (including a vendor, provider,
organization, agency, or other entity, or an alternate
payee thereof, but excluding a recipient) who:
(a) knowingly presents or causes to be presented
to an officer, employee, or agent of the State, a claim
that the Department determines:
(i) is for a medical or other item or service
that the person knows or should know was not
provided as claimed, including any person who
engages in a pattern or practice of presenting or
causing to be presented a claim for an item or
service that is based on a code that the person
knows or should know will result in a greater
payment to the person than the code the person
knows or should know is applicable to the item or
service actually provided;
(ii) is for a medical or other item or service
and the person knows or should know that the claim
is false or fraudulent;
(iii) is presented for a vendor physician's
service, or an item or service incident to a
vendor physician's service, by a person who knows
or should know that the individual who furnished,
or supervised the furnishing of, the service:
(AA) was not licensed as a physician;
(BB) was licensed as a physician but such

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license had been obtained through a
misrepresentation of material fact (including
cheating on an examination required for
licensing); or
(CC) represented to the patient at the
time the service was furnished that the
physician was certified in a medical specialty
by a medical specialty board, when the
individual was not so certified;
(iv) is for a medical or other item or service
furnished during a period in which the person was
excluded from the medical assistance program or a
federal or state health care program under which
the claim was made pursuant to applicable law; or
(v) is for a pattern of medical or other items
or services that a person knows or should know are
not medically necessary;
(b) knowingly presents or causes to be presented
to any person a request for payment which is in
violation of the conditions for receipt of vendor
payments under the medical assistance program under
Section 11-13 of this Code;
(c) knowingly gives or causes to be given to any
person, with respect to medical assistance program
coverage of inpatient hospital services, information
that he or she knows or should know is false or

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misleading, and that could reasonably be expected to
influence the decision when to discharge such person
or other individual from the hospital;
(d) in the case of a person who is not an
organization, agency, or other entity, is excluded
from participating in the medical assistance program
or a federal or state health care program and who, at
the time of a violation of this subsection (E-5):
(i) retains a direct or indirect ownership or
control interest in an entity that is
participating in the medical assistance program or
a federal or state health care program, and who
knows or should know of the action constituting
the basis for the exclusion; or
(ii) is an officer or managing employee of
such an entity;
(e) offers or transfers remuneration to any
individual eligible for benefits under the medical
assistance program that such person knows or should
know is likely to influence such individual to order
or receive from a particular vendor, provider,
practitioner, or supplier any item or service for
which payment may be made, in whole or in part, under
the medical assistance program;
(f) arranges or contracts (by employment or
otherwise) with an individual or entity that the

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person knows or should know is excluded from
participation in the medical assistance program or a
federal or state health care program, for the
provision of items or services for which payment may
be made under such a program;
(g) commits an act described in subsection (b) or
(c) of Section 8A-3;
(h) knowingly makes, uses, or causes to be made or
used, a false record or statement material to a false
or fraudulent claim for payment for items and services
furnished under the medical assistance program;
(i) fails to grant timely access, upon reasonable
request (as defined by the Department by rule), to the
Inspector General, for the purpose of audits,
investigations, evaluations, or other statutory
functions of the Inspector General of the Department;
(j) orders or prescribes a medical or other item
or service during a period in which the person was
excluded from the medical assistance program or a
federal or state health care program, in the case
where the person knows or should know that a claim for
such medical or other item or service will be made
under such a program;
(k) knowingly makes or causes to be made any false
statement, omission, or misrepresentation of a
material fact in any application, bid, or contract to

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participate or enroll as a vendor or provider of
services or a supplier under the medical assistance
program;
(l) knows of an overpayment and does not report
and return the overpayment to the Department in
accordance with paragraph (6);
shall be subject, in addition to any other penalties that
may be prescribed by law, to a civil money penalty of not
more than $10,000 for each item or service (or, in cases
under subparagraph (c), $15,000 for each individual with
respect to whom false or misleading information was given;
in cases under subparagraph (d), $10,000 for each day the
prohibited relationship occurs; in cases under
subparagraph (g), $50,000 for each such act; in cases
under subparagraph (h), $50,000 for each false record or
statement; in cases under subparagraph (i), $15,000 for
each day of the failure described in such subparagraph; or
in cases under subparagraph (k), $50,000 for each false
statement, omission, or misrepresentation of a material
fact). In addition, such a person shall be subject to an
assessment of not more than 3 times the amount claimed for
each such item or service in lieu of damages sustained by
the State because of such claim (or, in cases under
subparagraph (g), damages of not more than 3 times the
total amount of remuneration offered, paid, solicited, or
received, without regard to whether a portion of such

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remuneration was offered, paid, solicited, or received for
a lawful purpose; or in cases under subparagraph (k), an
assessment of not more than 3 times the total amount
claimed for each item or service for which payment was
made based upon the application, bid, or contract
containing the false statement, omission, or
misrepresentation of a material fact).
(3) In addition, the Director or his or her designee
may make a determination in the same proceeding to
exclude, terminate, suspend, or bar the person from
participation in the medical assistance program.
(4) The Illinois Department may seek the civil
monetary penalties and exclusion, termination, suspension,
or barment identified in this subsection (E-5). Prior to
the imposition of any penalties or sanctions, the affected
person shall be afforded an opportunity for a hearing
after reasonable notice. The Department shall establish
hearing procedures by rule.
(5) Any final order, decision, or other determination
made, issued, or executed by the Director under the
provisions of this subsection (E-5), whereby a person is
aggrieved, shall be subject to review in accordance with
the provisions of the Administrative Review Law, and the
rules adopted pursuant thereto, which shall apply to and
govern all proceedings for the judicial review of final
administrative decisions of the Director.

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(6)(a) If a person has received an overpayment, the
person shall:
(i) report and return the overpayment to the
Department at the correct address; and
(ii) notify the Department in writing of the
reason for the overpayment.
(b) An overpayment must be reported and returned under
subparagraph (a) by the later of:
(i) the date which is 60 days after the date on
which the overpayment was identified; or
(ii) the date any corresponding cost report is
due, if applicable.
(E-10) A vendor who disputes an overpayment identified as
part of a Department audit shall utilize the Department's
self-referral disclosure protocol as set forth under this Code
to identify, investigate, and return to the Department any
undisputed audit overpayment amount. Unless the disputed
overpayment amount is subject to a fraud payment suspension,
or involves a termination sanction, the Department shall defer
the recovery of the disputed overpayment amount up to one year
after the date of the Department's final audit determination,
or earlier, or as required by State or federal law. If the
administrative hearing extends beyond one year, and such delay
was not caused by the request of the vendor, then the
Department shall not recover the disputed overpayment amount
until the date of the final administrative decision. If a

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final administrative decision establishes that the disputed
overpayment amount is owed to the Department, then the amount
shall be immediately due to the Department. The Department
shall be entitled to recover interest from the vendor on the
overpayment amount from the date of the overpayment through
the date the vendor returns the overpayment to the Department
at a rate not to exceed the Wall Street Journal Prime Rate, as
published from time to time, but not to exceed 5%. Any interest
billed by the Department shall be due immediately upon receipt
of the Department's billing statement.
(F) The Illinois Department may withhold payments to any
vendor or alternate payee prior to or during the pendency of
any audit or proceeding under this Section, and through the
pendency of any administrative appeal or administrative review
by any court proceeding. The Illinois Department shall state
by rule with as much specificity as practicable the conditions
under which payments will not be withheld under this Section.
Payments may be denied for bills submitted with service dates
occurring during the pendency of a proceeding, after a final
decision has been rendered, or after the conclusion of any
administrative appeal, where the final administrative decision
is to terminate, exclude, or suspend eligibility to
participate in the medical assistance program. The Illinois
Department shall state by rule with as much specificity as
practicable the conditions under which payments will not be
denied for such bills. The Illinois Department shall state by

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rule a process and criteria by which a vendor or alternate
payee may request full or partial release of payments withheld
under this subsection. The Department must complete a
proceeding under this Section in a timely manner.
Notwithstanding recovery allowed under subsection (E) or
this subsection (F), the Illinois Department may withhold
payments to any vendor or alternate payee who is not properly
licensed, certified, or in compliance with State or federal
agency regulations. Payments may be denied for bills submitted
with service dates occurring during the period of time that a
vendor is not properly licensed, certified, or in compliance
with State or federal regulations. Facilities licensed under
the Nursing Home Care Act shall have payments denied or
withheld pursuant to subsection (I) of this Section.
(F-5) The Illinois Department may temporarily withhold
payments to a vendor or alternate payee if any of the following
individuals have been indicted or otherwise charged under a
law of the United States or this or any other state with an
offense that is based on alleged fraud or willful
misrepresentation on the part of the individual related to (i)
the medical assistance program under Article V of this Code,
(ii) a federal or another state's medical assistance or health
care program, or (iii) the provision of health care services:
(1) If the vendor or alternate payee is a corporation:
an officer of the corporation or an individual who owns,
either directly or indirectly, 5% or more of the shares of

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stock or other evidence of ownership of the corporation.
(2) If the vendor is a sole proprietorship: the owner
of the sole proprietorship.
(3) If the vendor or alternate payee is a partnership:
a partner in the partnership.
(4) If the vendor or alternate payee is any other
business entity authorized by law to transact business in
this State: an officer of the entity or an individual who
owns, either directly or indirectly, 5% or more of the
evidences of ownership of the entity.
If the Illinois Department withholds payments to a vendor
or alternate payee under this subsection, the Department shall
not release those payments to the vendor or alternate payee
while any criminal proceeding related to the indictment or
charge is pending unless the Department determines that there
is good cause to release the payments before completion of the
proceeding. If the indictment or charge results in the
individual's conviction, the Illinois Department shall retain
all withheld payments, which shall be considered forfeited to
the Department. If the indictment or charge does not result in
the individual's conviction, the Illinois Department shall
release to the vendor or alternate payee all withheld
payments.
(F-10) If the Illinois Department establishes that the
vendor or alternate payee owes a debt to the Illinois
Department, and the vendor or alternate payee subsequently

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fails to pay or make satisfactory payment arrangements with
the Illinois Department for the debt owed, the Illinois
Department may seek all remedies available under the law of
this State to recover the debt, including, but not limited to,
wage garnishment or the filing of claims or liens against the
vendor or alternate payee.
(F-15) Enforcement of judgment.
(1) Any fine, recovery amount, other sanction, or
costs imposed, or part of any fine, recovery amount, other
sanction, or cost imposed, remaining unpaid after the
exhaustion of or the failure to exhaust judicial review
procedures under the Illinois Administrative Review Law is
a debt due and owing the State and may be collected using
all remedies available under the law.
(2) After expiration of the period in which judicial
review under the Illinois Administrative Review Law may be
sought for a final administrative decision, unless stayed
by a court of competent jurisdiction, the findings,
decision, and order of the Director may be enforced in the
same manner as a judgment entered by a court of competent
jurisdiction.
(3) In any case in which any person or entity has
failed to comply with a judgment ordering or imposing any
fine or other sanction, any expenses incurred by the
Illinois Department to enforce the judgment, including,
but not limited to, attorney's fees, court costs, and

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costs related to property demolition or foreclosure, after
they are fixed by a court of competent jurisdiction or the
Director, shall be a debt due and owing the State and may
be collected in accordance with applicable law. Prior to
any expenses being fixed by a final administrative
decision pursuant to this subsection (F-15), the Illinois
Department shall provide notice to the individual or
entity that states that the individual or entity shall
appear at a hearing before the administrative hearing
officer to determine whether the individual or entity has
failed to comply with the judgment. The notice shall set
the date for such a hearing, which shall not be less than 7
days from the date that notice is served. If notice is
served by mail, the 7-day period shall begin to run on the
date that the notice was deposited in the mail.
(4) Upon being recorded in the manner required by
Article XII of the Code of Civil Procedure or by the
Uniform Commercial Code, a lien shall be imposed on the
real estate or personal estate, or both, of the individual
or entity in the amount of any debt due and owing the State
under this Section. The lien may be enforced in the same
manner as a judgment of a court of competent jurisdiction.
A lien shall attach to all property and assets of such
person, firm, corporation, association, agency,
institution, or other legal entity until the judgment is
satisfied.

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(5) The Director may set aside any judgment entered by
default and set a new hearing date upon a petition filed at
any time (i) if the petitioner's failure to appear at the
hearing was for good cause, or (ii) if the petitioner
established that the Department did not provide proper
service of process. If any judgment is set aside pursuant
to this paragraph (5), the hearing officer shall have
authority to enter an order extinguishing any lien which
has been recorded for any debt due and owing the Illinois
Department as a result of the vacated default judgment.
(G) The provisions of the Administrative Review Law, as
now or hereafter amended, and the rules adopted pursuant
thereto, shall apply to and govern all proceedings for the
judicial review of final administrative decisions of the
Illinois Department under this Section. The term
"administrative decision" is defined as in Section 3-101 of
the Code of Civil Procedure.
(G-5) Vendors who pose a risk of fraud, waste, abuse, or
harm.
(1) Notwithstanding any other provision in this
Section, the Department may terminate, suspend, or exclude
vendors who pose a risk of fraud, waste, abuse, or harm
from participation in the medical assistance program prior
to an evidentiary hearing but after reasonable notice and
opportunity to respond as established by the Department by
rule.

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(2) Vendors who pose a risk of fraud, waste, abuse, or
harm shall submit to a fingerprint-based criminal
background check on current and future information
available in the State system and current information
available through the Federal Bureau of Investigation's
system by submitting all necessary fees and information in
the form and manner prescribed by the Illinois State
Police. The following individuals shall be subject to the
check:
(A) In the case of a vendor that is a corporation,
every shareholder who owns, directly or indirectly, 5%
or more of the outstanding shares of the corporation.
(B) In the case of a vendor that is a partnership,
every partner.
(C) In the case of a vendor that is a sole
proprietorship, the sole proprietor.
(D) Each officer or manager of the vendor.
Each such vendor shall be responsible for payment of
the cost of the criminal background check.
(3) Vendors who pose a risk of fraud, waste, abuse, or
harm may be required to post a surety bond. The Department
shall establish, by rule, the criteria and requirements
for determining when a surety bond must be posted and the
value of the bond.
(4) The Department, or its agents, may refuse to
accept requests for authorization from specific vendors

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who pose a risk of fraud, waste, abuse, or harm, including
prior-approval and post-approval requests, if:
(A) the Department has initiated a notice of
termination, suspension, or exclusion of the vendor
from participation in the medical assistance program;
or
(B) the Department has issued notification of its
withholding of payments pursuant to subsection (F-5)
of this Section; or
(C) the Department has issued a notification of
its withholding of payments due to reliable evidence
of fraud or willful misrepresentation pending
investigation.
(5) As used in this subsection, the following terms
are defined as follows:
(A) "Fraud" means an intentional deception or
misrepresentation made by a person with the knowledge
that the deception could result in some unauthorized
benefit to himself or herself or some other person. It
includes any act that constitutes fraud under
applicable federal or State law.
(B) "Abuse" means provider practices that are
inconsistent with sound fiscal, business, or medical
practices and that result in an unnecessary cost to
the medical assistance program or in reimbursement for
services that are not medically necessary or that fail

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to meet professionally recognized standards for health
care. It also includes recipient practices that result
in unnecessary cost to the medical assistance program.
Abuse does not include diagnostic or therapeutic
measures conducted primarily as a safeguard against
possible vendor liability.
(C) "Waste" means the unintentional misuse of
medical assistance resources, resulting in unnecessary
cost to the medical assistance program. Waste does not
include diagnostic or therapeutic measures conducted
primarily as a safeguard against possible vendor
liability.
(D) "Harm" means physical, mental, or monetary
damage to recipients or to the medical assistance
program.
(G-6) The Illinois Department, upon making a determination
based upon information in the possession of the Illinois
Department that continuation of participation in the medical
assistance program by a vendor would constitute an immediate
danger to the public, may immediately suspend such vendor's
participation in the medical assistance program without a
hearing. In instances in which the Illinois Department
immediately suspends the medical assistance program
participation of a vendor under this Section, a hearing upon
the vendor's participation must be convened by the Illinois
Department within 15 days after such suspension and completed

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without appreciable delay. Such hearing shall be held to
determine whether to recommend to the Director that the
vendor's medical assistance program participation be denied,
terminated, suspended, placed on provisional status, or
reinstated. In the hearing, any evidence relevant to the
vendor constituting an immediate danger to the public may be
introduced against such vendor; provided, however, that the
vendor, or his or her counsel, shall have the opportunity to
discredit, impeach, and submit evidence rebutting such
evidence.
(H) Nothing contained in this Code shall in any way limit
or otherwise impair the authority or power of any State agency
responsible for licensing of vendors.
(I) Based on a finding of noncompliance on the part of a
nursing home with any requirement for certification under
Title XVIII or XIX of the Social Security Act (42 U.S.C. Sec.
1395 et seq. or 42 U.S.C. Sec. 1396 et seq.), the Illinois
Department may impose one or more of the following remedies
after notice to the facility:
(1) Termination of the provider agreement.
(2) Temporary management.
(3) Denial of payment for new admissions.
(4) Civil money penalties.
(5) Closure of the facility in emergency situations or
transfer of residents, or both.
(6) State monitoring.

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(7) Denial of all payments when the U.S. Department of
Health and Human Services has imposed this sanction.
The Illinois Department shall by rule establish criteria
governing continued payments to a nursing facility subsequent
to termination of the facility's provider agreement if, in the
sole discretion of the Illinois Department, circumstances
affecting the health, safety, and welfare of the facility's
residents require those continued payments. The Illinois
Department may condition those continued payments on the
appointment of temporary management, sale of the facility to
new owners or operators, or other arrangements that the
Illinois Department determines best serve the needs of the
facility's residents.
Except in the case of a facility that has a right to a
hearing on the finding of noncompliance before an agency of
the federal government, a facility may request a hearing
before a State agency on any finding of noncompliance within
60 days after the notice of the intent to impose a remedy.
Except in the case of civil money penalties, a request for a
hearing shall not delay imposition of the penalty. The choice
of remedies is not appealable at a hearing. The level of
noncompliance may be challenged only in the case of a civil
money penalty. The Illinois Department shall provide by rule
for the State agency that will conduct the evidentiary
hearings.
The Illinois Department may collect interest on unpaid

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civil money penalties.
The Illinois Department may adopt all rules necessary to
implement this subsection (I).
(J) The Illinois Department, by rule, may permit
individual practitioners to designate that Department payments
that may be due the practitioner be made to an alternate payee
or alternate payees.
(a) Such alternate payee or alternate payees shall be
required to register as an alternate payee in the Medical
Assistance Program with the Illinois Department.
(b) If a practitioner designates an alternate payee,
the alternate payee and practitioner shall be jointly and
severally liable to the Department for payments made to
the alternate payee. Pursuant to subsection (E) of this
Section, any Department action to suspend or deny payment
or recover money or overpayments from an alternate payee
shall be subject to an administrative hearing.
(c) Registration as an alternate payee or alternate
payees in the Illinois Medical Assistance Program shall be
conditional. At any time, the Illinois Department may deny
or cancel any alternate payee's registration in the
Illinois Medical Assistance Program without cause. Any
such denial or cancellation is not subject to an
administrative hearing.
(d) The Illinois Department may seek a revocation of
any alternate payee, and all owners, officers, and

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individuals with management responsibility for such
alternate payee shall be permanently prohibited from
participating as an owner, an officer, or an individual
with management responsibility with an alternate payee in
the Illinois Medical Assistance Program, if after
reasonable notice and opportunity for a hearing the
Illinois Department finds that:
(1) the alternate payee is not complying with the
Department's policy or rules and regulations, or with
the terms and conditions prescribed by the Illinois
Department in its alternate payee registration
agreement; or
(2) the alternate payee has failed to keep or make
available for inspection, audit, or copying, after
receiving a written request from the Illinois
Department, such records regarding payments claimed as
an alternate payee; or
(3) the alternate payee has failed to furnish any
information requested by the Illinois Department
regarding payments claimed as an alternate payee; or
(4) the alternate payee has knowingly made, or
caused to be made, any false statement or
representation of a material fact in connection with
the administration of the Illinois Medical Assistance
Program; or
(5) the alternate payee, a person with management

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responsibility for an alternate payee, an officer or
person owning, either directly or indirectly, 5% or
more of the shares of stock or other evidences of
ownership in a corporate alternate payee, or a partner
in a partnership which is an alternate payee:
(a) was previously terminated, suspended, or
excluded from participation as a vendor in the
Illinois Medical Assistance Program, or was
previously revoked as an alternate payee in the
Illinois Medical Assistance Program, or was
terminated, suspended, or excluded from
participation as a vendor in a medical assistance
program in another state that is of the same kind
as the program of medical assistance provided
under Article V of this Code; or
(b) was a person with management
responsibility for a vendor previously terminated,
suspended, or excluded from participation as a
vendor in the Illinois Medical Assistance Program,
or was previously revoked as an alternate payee in
the Illinois Medical Assistance Program, or was
terminated, suspended, or excluded from
participation as a vendor in a medical assistance
program in another state that is of the same kind
as the program of medical assistance provided
under Article V of this Code, during the time of

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conduct which was the basis for that vendor's
termination, suspension, or exclusion or alternate
payee's revocation; or
(c) was an officer, or person owning, either
directly or indirectly, 5% or more of the shares
of stock or other evidences of ownership in a
corporate vendor previously terminated, suspended,
or excluded from participation as a vendor in the
Illinois Medical Assistance Program, or was
previously revoked as an alternate payee in the
Illinois Medical Assistance Program, or was
terminated, suspended, or excluded from
participation as a vendor in a medical assistance
program in another state that is of the same kind
as the program of medical assistance provided
under Article V of this Code, during the time of
conduct which was the basis for that vendor's
termination, suspension, or exclusion; or
(d) was an owner of a sole proprietorship or
partner in a partnership previously terminated,
suspended, or excluded from participation as a
vendor in the Illinois Medical Assistance Program,
or was previously revoked as an alternate payee in
the Illinois Medical Assistance Program, or was
terminated, suspended, or excluded from
participation as a vendor in a medical assistance

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program in another state that is of the same kind
as the program of medical assistance provided
under Article V of this Code, during the time of
conduct which was the basis for that vendor's
termination, suspension, or exclusion or alternate
payee's revocation; or
(6) the alternate payee, a person with management
responsibility for an alternate payee, an officer or
person owning, either directly or indirectly, 5% or
more of the shares of stock or other evidences of
ownership in a corporate alternate payee, or a partner
in a partnership which is an alternate payee:
(a) has engaged in conduct prohibited by
applicable federal or State law or regulation
relating to the Illinois Medical Assistance
Program; or
(b) was a person with management
responsibility for a vendor or alternate payee at
the time that the vendor or alternate payee
engaged in practices prohibited by applicable
federal or State law or regulation relating to the
Illinois Medical Assistance Program; or
(c) was an officer, or person owning, either
directly or indirectly, 5% or more of the shares
of stock or other evidences of ownership in a
vendor or alternate payee at the time such vendor

10400SB3365ham001 - 552 - LRB104 18483 KTG 38682 a
or alternate payee engaged in practices prohibited
by applicable federal or State law or regulation
relating to the Illinois Medical Assistance
Program; or
(d) was an owner of a sole proprietorship or
partner in a partnership which was a vendor or
alternate payee at the time such vendor or
alternate payee engaged in practices prohibited by
applicable federal or State law or regulation
relating to the Illinois Medical Assistance
Program; or
(7) the direct or indirect ownership of the vendor
or alternate payee (including the ownership of a
vendor or alternate payee that is a partner's interest
in a vendor or alternate payee, or ownership of 5% or
more of the shares of stock or other evidences of
ownership in a corporate vendor or alternate payee)
has been transferred by an individual who is
terminated, suspended, or excluded or barred from
participating as a vendor or is prohibited or revoked
as an alternate payee to the individual's spouse,
child, brother, sister, parent, grandparent,
grandchild, uncle, aunt, niece, nephew, cousin, or
relative by marriage.
(K) The Illinois Department of Healthcare and Family
Services may withhold payments, in whole or in part, to a

10400SB3365ham001 - 553 - LRB104 18483 KTG 38682 a
provider or alternate payee where there is credible evidence,
received from State or federal law enforcement or federal
oversight agencies or from the results of a preliminary
Department audit, that the circumstances giving rise to the
need for a withholding of payments may involve fraud or
willful misrepresentation under the Illinois Medical
Assistance program. The Department shall by rule define what
constitutes "credible" evidence for purposes of this
subsection. The Department may withhold payments without first
notifying the provider or alternate payee of its intention to
withhold such payments. A provider or alternate payee may
request a reconsideration of payment withholding, and the
Department must grant such a request. The Department shall
state by rule a process and criteria by which a provider or
alternate payee may request full or partial release of
payments withheld under this subsection. This request may be
made at any time after the Department first withholds such
payments.
(a) The Illinois Department must send notice of its
withholding of program payments within 5 days of taking
such action. The notice must set forth the general
allegations as to the nature of the withholding action,
but need not disclose any specific information concerning
its ongoing investigation. The notice must do all of the
following:
(1) State that payments are being withheld in

10400SB3365ham001 - 554 - LRB104 18483 KTG 38682 a
accordance with this subsection.
(2) State that the withholding is for a temporary
period, as stated in paragraph (b) of this subsection,
and cite the circumstances under which withholding
will be terminated.
(3) Specify, when appropriate, which type or types
of Medicaid claims withholding is effective.
(4) Inform the provider or alternate payee of the
right to submit written evidence for reconsideration
of the withholding by the Illinois Department.
(5) Inform the provider or alternate payee that a
written request may be made to the Illinois Department
for full or partial release of withheld payments and
that such requests may be made at any time after the
Department first withholds such payments.
(b) All withholding-of-payment actions under this
subsection shall be temporary and shall not continue after
any of the following:
(1) The Illinois Department or the prosecuting
authorities determine that there is insufficient
evidence of fraud or willful misrepresentation by the
provider or alternate payee.
(2) Legal proceedings related to the provider's or
alternate payee's alleged fraud, willful
misrepresentation, violations of this Act, or
violations of the Illinois Department's administrative

10400SB3365ham001 - 555 - LRB104 18483 KTG 38682 a
rules are completed.
(3) The withholding of payments for a period of 3
years.
(c) The Illinois Department may adopt all rules
necessary to implement this subsection (K).
(K-5) The Illinois Department may withhold payments, in
whole or in part, to a provider or alternate payee upon
initiation of an audit, quality of care review, investigation
when there is a credible allegation of fraud, or the provider
or alternate payee demonstrating a clear failure to cooperate
with the Illinois Department such that the circumstances give
rise to the need for a withholding of payments. As used in this
subsection, "credible allegation" is defined to include an
allegation from any source, including, but not limited to,
fraud hotline complaints, claims data mining, patterns
identified through provider audits, civil actions filed under
the Illinois False Claims Act, and law enforcement
investigations. An allegation is considered to be credible
when it has indicia of reliability. The Illinois Department
may withhold payments without first notifying the provider or
alternate payee of its intention to withhold such payments. A
provider or alternate payee may request a hearing or a
reconsideration of payment withholding, and the Illinois
Department must grant such a request. The Illinois Department
shall state by rule a process and criteria by which a provider
or alternate payee may request a hearing or a reconsideration

10400SB3365ham001 - 556 - LRB104 18483 KTG 38682 a
for the full or partial release of payments withheld under
this subsection. This request may be made at any time after the
Illinois Department first withholds such payments.
(a) The Illinois Department must send notice of its
withholding of program payments within 5 days of taking
such action. The notice must set forth the general
allegations as to the nature of the withholding action but
need not disclose any specific information concerning its
ongoing investigation. The notice must do all of the
following:
(1) State that payments are being withheld in
accordance with this subsection.
(2) State that the withholding is for a temporary
period, as stated in paragraph (b) of this subsection,
and cite the circumstances under which withholding
will be terminated.
(3) Specify, when appropriate, which type or types
of claims are withheld.
(4) Inform the provider or alternate payee of the
right to request a hearing or a reconsideration of the
withholding by the Illinois Department, including the
ability to submit written evidence.
(5) Inform the provider or alternate payee that a
written request may be made to the Illinois Department
for a hearing or a reconsideration for the full or
partial release of withheld payments and that such

10400SB3365ham001 - 557 - LRB104 18483 KTG 38682 a
requests may be made at any time after the Illinois
Department first withholds such payments.
(b) All withholding of payment actions under this
subsection shall be temporary and shall not continue after
any of the following:
(1) The Illinois Department determines that there
is insufficient evidence of fraud, or the provider or
alternate payee demonstrates clear cooperation with
the Illinois Department, as determined by the Illinois
Department, such that the circumstances do not give
rise to the need for withholding of payments; or
(2) The withholding of payments has lasted for a
period in excess of 3 years.
(c) The Illinois Department may adopt all rules
necessary to implement this subsection (K-5).
(L) The Illinois Department shall establish a protocol to
enable health care providers to disclose an actual or
potential violation of this Section pursuant to a
self-referral disclosure protocol, referred to in this
subsection as "the protocol". The protocol shall include
direction for health care providers on a specific person,
official, or office to whom such disclosures shall be made.
The Illinois Department shall post information on the protocol
on the Illinois Department's public website. The Illinois
Department may adopt rules necessary to implement this
subsection (L). In addition to other factors that the Illinois

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Department finds appropriate, the Illinois Department may
consider a health care provider's timely use or failure to use
the protocol in considering the provider's failure to comply
with this Code.
(M) Notwithstanding any other provision of this Code, the
Illinois Department, at its discretion, may exempt an entity
licensed under the Nursing Home Care Act, the ID/DD Community
Care Act, or the MC/DD Act from the provisions of subsections
(A-15), (B), and (C) of this Section if the licensed entity is
in receivership.
(O) Enforcement of advance payment agreements. To the
extent not prohibited by federal or State law, and
notwithstanding any other provision of this Code, if a
provider fails to comply with the terms of an advance payment
agreement, the Department is authorized to collect any unpaid
advance balance through one or more of the following methods:
(1) Direct withholding of Department reimbursements.
The Department may withhold reimbursement or other amounts
otherwise payable by the Department to the provider,
including, but not limited to, fee-for-service claims
payments, supplemental payments, and any other amounts the
Department is obligated to pay the provider under the
medical assistance program, and apply such withheld
amounts as repayment of the unpaid advance.
(2) Managed care organizations remittance. If a
provider participates in a managed care program

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administered by the Department, the Department may direct
the managed care organization to remit to the Department
amounts otherwise payable by the managed care organization
to the provider, and apply such remitted amounts as
repayment of the unpaid advance.
The requirements of this subsection may be waived by the
Department in instances when a nursing home provider has
entered into and remains in compliance with a renegotiated
advance payment agreement. A renegotiated advance payment
agreement must be entered into no later than 60 days after the
effective date of this amendatory Act of the 104th General
Assembly.
A nursing home must enter into a renegotiated advance
payment agreement with the Department that includes terms for
repayment of the total amount owed for all outstanding amounts
over a 12-month period, repaid in equal payment increments.
Payments shall begin within 30 days of the signed agreement
date.
Failure to remain in compliance with a renegotiated
advance payment agreement shall cause immediate termination of
such an agreement unless there is prior written consent from
the Department for a period of non-compliance.
Beginning September 1, 2026, the Department shall
immediately collect all overdue unpaid advance debts through
the collection methods authorized under this Section, unless a
renegotiated advance payment agreement has already been agreed

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to.
(Source: P.A. 102-538, eff. 8-20-21.)
ARTICLE 800.
Section 800-95. No acceleration or delay. Where this Act
makes changes in a statute that is represented in this Act by
text that is not yet or no longer in effect (for example, a
Section represented by multiple versions), the use of that
text does not accelerate or delay the taking effect of (i) the
changes made by this Act or (ii) provisions derived from any
other Public Act.
ARTICLE 999.
Section 999-99. Effective date. This Act takes effect upon
becoming law, except that Section 257-10 of Article 257 and
Articles 2, 10, 15, and 225 take effect July 1, 2026, and
Article 6 takes effect January 1, 2027, and Article 65 takes
effect July 1, 2027.".